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ROCKEFELLER  F0UNt>Atir01 

[INTERNATIONAL  HEALTH  COMMISSION 


The  Eradication  of  Ankylostomiasis 

Methods  mid  Administrative  Measures  as  Illustrated 
by  the  Campaign  in  British  Gtciana, 


By  H.  H.  HOWARD,  M.  D, 

Director  for  the  West  Jndief 


^ 


OFFICES  OF  THE  CXjUU 
Washington  D,  C.  I:   '- 


Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/eradicationofankOOhowarich 


ROCKEFELLER  FOUNDATION 
INTERNATIONAL  HEALTH   COMMISSION 


The  Eradication  of  Ankylostomiasis 

Methods  and  Administrative  Measures  as  Illustrated 
by  the  Campaign  in  British  Guiana, 


By  H.  H.  I^I^OWARD,  M.  D. 

Director  for  the  West  Indies 


OFFICES  OF  THE  COMMISSION 

Washington,  D.  C,  U.  S.  A. 

1915 


--1-5 


('      MEMBERS  OF  THE  COMMISSION  biology 


John  D.  Rockefeller,  Jr.,  Chairman. 
Jerome  D.  Greene,  Recording  Secretary. 
WiCKLiFFE  Rose,  Director-General. 

Charles  W.  Eliot  Charles  O.  Heydt 

Simon  Flexner  David  F.  Houston 

Frederick  T.  Gates  Starr  J.  Murphy 

William  C.  Gorgas  Walter  H.  Page 

William  H.  Welch 


LIBRARY 


OFFICERS  OF  THE  COMMISSION 

WiCKLiFFE  Rose,  LL.D.        .        .        .        .        .        .  Director -General 

John  A.  FerrELL,  M.  D Assistant  Director-General 

Ernst  C.  Meyer,  Ph.D.        .        .        .       Director  of  Surveys  and  Exhibits 
J.  H.  White,  M.  D.         .        .        .        .        .       Director  for  Latin  America 

H.  H.  Howard,  M.  D.    , Director  for  the  West  Indies 

Victor  Heiser,  M.  D;  ...        .  .      Director  for  the  East 


ENGLISH  ADVISORY  COMMITTEE 

The  Right  Hon.  Viscount  Bryce,  O.M.,  Chairman. 

Professor  J.  S.  Haldane,  F.R.S. 

Dr  A.  E.  vShiplEy,  F.R.S. 

Dr.  A.  G.  Bagshawe,  Director  of  the  Tropical  Diseases  Bureau. 

Surgeon-General  Sir  R.  Havelock  Charles,  G.C.V.O.,  Representing  the 

•  ••  ,.^         Indian  Gov^roment. 

Major  Sir  T.  B.«R»binsqn,V^.^;M.G.;  Agent-General  for  Queensland. 

/*  : : ;;  ^i  p,  JVLcCAi,mM,us.c.M.G. 
•''•••*  'sTr  'P..  m!  frioDi^on,  -:^?c . m  . g. 

Sir  David  SemplE;  Representing  the  Egyptian  Government. 
Mr.  H.  J.  Read,  C.M.G.,  of  the  Colonial  Office. 
Mr.  G.  GrindlE,  of  the  Colonial  Office. 
Mr  H.  R.  CowELL,  of  the  Colonial  Office,  .Secretary. 


St. 


INTRODUCTORY  NOTE. 

This  pamphlet  has  been  prepared  in  answer  to  numerous 
requests,  received  from  both  official  and  private  sources,  for 
information  regarding  the  administrative  problems  of  the  work 
of  the  eradication  of  Ankylostomiasis. 

From  a  knowledge  of  the  methods  in  use  during  the  last  four 
years  in  Ankylostome  eradication  in  the  United  States,  together 
with  the  experience  gained  in  the  introduction  and  establish- 
ment of  the  work  in  British  Guiana,  the  attempt  has  been  made 
in  these  pages  to  place  at  the  disposal  of  any  who  may  be  inter- 
ested, the  resulting  considerations.  It  is  hoped  that  they  may 
be  of  value  in  the  introduction  of  the  work  into  new  territory, 
where  they  may  serve,  if  in  no  other  way,  as  a  starting-point 
from  which  better  methods  may  be  developed  and  perfected. 

Special  attention  is  called  to  the  forms  which  appear  in  the 
last  pages.  It  is  most  important  that  an  accurate,  comprehen- 
sive, intelligible  record  be  made  of  all  work  done.  The  forms 
submitted  show  how  this  was  done  in  British  Guiana.  The 
methods  set  forth  have  met  the  test  of  practical  application 
and  would  seem  worthy  of  trial  wherever  such  work  is  to  be 
undertaken. 

H.  H.  Howard,  M.  D., 
Director  for  the JV est  Indies. 


430288 

Washington,  D.  C,  September  i^,  1914- 


THE  ERADICATION  OF  HOOKWORM  DISEASE. 

This  subject  is  discussed  under  thirteen  heads,  indicating  the 
successive  steps  in  the  development  of  the  work,  as  follows : 

1 .  Selection  of  Unit  of  Area  of  Operation. 

2.  Publicity  and  Educational  Measures. 

3.  Census  Taking. 

4.  Microscopic  Examination. 

5.  Treatment. 

6.  Re-examination. 

7.  Working  Force. 

8.  Financial  Procedures. 

9.  Duration  of  Campaign. 

ID.  Sanitary  Measures  for  Prevention. 

1 1 .  Per  Capita  Cost. 

12.  Is  Complete  Eradication  Possible? 

13.  Forms  and  System  of  Reports. 


1.  SELECTION  OF  UNIT  OF  AREA  OF  OPERATIONS. 

The  first  attempt  at  complete  eradication  of  Ankylostomiasis 
in  foreign  fields  in  which  the  International  Health  Commission 
has  co-operated  was  in  British  Guiana.  It  had  its  beginning 
in  the  early  months  of  19 14. 

Following  a  visit  of  Mr.  Wickliffe  Rose,  Director-General  of 
the  International  Health  Commission,  to  that  Colony  in  October 
19 13,  a  working-plan  and  budget  were  prepared  by  the  Surgeon- 
General,  with  the  assistance  of  Dr.  J.  E.  A.  Ferguson,  Medical 
Officer  of  Peter's  Hall  District,  and  submitted  to  the  Inter- 
national Health  Commission.  The  plan  and  budget  having 
been  adopted,  it  was  determined  that  the  area  of  operation 
in  this  preliminary  campaign  should  be  a  Medical  District. 
"  Peter's  Hall  District,  just  south  of  the  city  of  Georgetown, 
was  selected.  This  District  is  approximately  eight  miles  long 
and  from  one  to  three  miles  wide,  with  a  population  of  14,000 
people,  exclusive  of  the  indentured  labor  of  the  sugar  planta- 
tions. 

In  this  territory  there  are  very  few  isolated  dwellings.  The 
people  live  in  a  chain  of  villages,  varying  in  size  from  200  to 
4,000  inhabitants,  lying  along  the  east  bank  of  the  Demerara 
River. 

We  were  not  to  deal  with  the  indentured  plantation  labor,  as 
this  feature  of  the  problem  was  being  handled  effectively  by  the 
District  Medical  Officer,  Dr.  J.  K.  A.  Ferguson,  the  cost  of  this 
work  being  borne  by  the  plantation  owners. 

On  March  9,  19 14,  I  arrived  at  Georgetown  and  was  cordially 
received  by  the  authorities  as  the  representative  of  the  Inter- 
national Health  Commission. 

Being  familiar  with  the  methods  in  use  by  the  Rockefeller 
Sanitary  Commission  in  combating  hookworm  disease  in  the 
United  States,  I  was  not  long  in  recognizing  that  there  were 
features  of  this  problem  in  British  Guiana  not  hitherto  met  with, 
either  in  the  work  done  in  the  United  States,  or  in  the  local 
effort  to  control  the  disease  among  the  indentured  coolies, 
because — 

I .  In  the  United  States  we  had  to  deal  with  a  fairly  intelligent 
population  of  whites  and  blacks  only,  and  with  sanitary  condi- 
tions uncomplicated  by  tropical  rainfall  and  temperatures;  while 


4  THIJ   ERADICATION   OF   HOOKWORM   DISEASE. 

the  transmission  of  the  disease  from  individual  to  individual 
is  prevented  during  a  considerable  portion  of  the  year  by  the 
low  temperatures  of  the  winter  season,  and  the  wearing  of  shoes. 
2.  The  local  effort  to  control  Ankylostomiasis  in  the  Colony 
had  been  confined  to  the  indentured  labor  of  the  sugar  estates — 
the  rather  docile  East  Indian  coolies,  who,  under  the  necessary 
plantation  discipline,  were  easily  handled  in  making  the  required 
examination  and  administering  treatment. 

Our  problem  was  to  eradicate  Ankylostomiasis  in  Peter's 
Hall  District  where  the  following  conditions  obtained : 

1.  Populated — 

(a)  By  East  Indians  who  had  served  out  their  indentures, 
and,  who,  together  with  the  remainder  of  the  population,  were 
no  longer  subject  to,  nor  tolerant  of,  discipline. 

(b)  By  Portuguese,  who  seem  especially  susceptible  to  the 
disease,  showing  a  large  proportion  of  severe  infections,  but  who, 
imfortunately,  were  often  indifferent  to  our  efforts  to  help  them. 

(c)  By  Chinese,  who  were  disinclined  to  take  medicine  unless 
suffering  acute  pain. 

(d)  By  "coloreds,"  who,  on  the  whole,  were  intelligent  and 
generally  favorable  to  our  campaign. 

(e)  By  "blacks,"  of  whom  the  more  ignorant  and  illiterate 
class  gave  us  the  most  trouble. 

2.  Re-infections  were  the  rule  rather  than  the  exceptions 
at  all  seasons  of  the  year  because  of  the  heavy  rainfall,  tropical 
temperature,  absence  of  shoes,  and  the  insanitary  habits  of  the 
people. 

It  must  be  obvious  that  the  task  of  unifying  these  very  diverse 
elements  of  population  and  creating  an  active  common  interest 
in  the  eradication  of  a  disease  about  which  they  were  unin- 
formed, was  no  small  undertaking.  Without  precedents  to 
follow,  it  was  determined  to  begin  experimentally  on  a  small 
scale,  and  to  test  and  develop  methods  by  which  our  task  could 
be  accomplished. 

To  this  end  Peter's  Hall  District  was  divided  into  three  areas 
varying  in  extent,  and  having  respectively  populations  of  8,ooo, 
3,500  and  2,800. 

A  more  careful  survey  of  the  territory  and  the  conditions  to 
be  met  led  us  to  limit  our  operations  still  further.  At  first,  they 
were  restricted  to  one  village  near  the  center  of  the  district. 
This  village,  Agricola,  had  a  population  of  1,335  and  presented 
average  conditions.  In  the  beginning  our  progress  was  naturally 
slow,  but  as  success  made  us  more  and  more  confident,  the  cam- 


PUBIvIGlTY  AND   KDUCATlONAIv   MEASURES.  $ 

paign  was  extended  to  other  villages  until  the  whole  of  the  area 
was  under  treatment. 

Our  experience  here  led  us  to  arrive  at  the  following  conclu- 
sions with  reference  to  what  should  be  a  "unit  of  area  of  opera- 
tion": 

A  territory  with — 

(a)  Legal  or  natural  boundaries. 

(b)  An  aggregate  of  population  of  not  more  than  15,000,  and 
fewer  if  sparsely  inhabited.  This  is  probably  the  maximum 
which  can  be  properly  handled  by  one  Medical  Officer  and  clerical 
force. 

(c)  A  Central  Office,  situated  near  the  center  of  the  District, 
where  most  of  the  clerical  and  microscopical  work  may  be  done, 
and  where  the  large  record-books  may  be  kept,  as  it  would  entail 
much  loss  of  time  and  expense  to  move  the  Central  Office  outfit 
from  village  to  village  during  the  progress  of  the  work. 

Wherever  possible,  a  map  of  the  Area  of  Operation  should  be 
made,  of  such  size  as  to  permit  the  indication  of  villages,  isolated 
dwellings,  schools,  water-courses,  roads,  drainage- trenches, 
water-reservoirs,  and  all  other  details  which  are  connected  in 
any  way  with  the  work  in  hand.  This  was  done,  as  far  as  was 
possible,  in  Peter's  Hall  District.  The  map  was  of  great  value 
to  the  Supervising  Medical  Officer  and  Staff,  as  it  gave  a  more 
definite  picture  of  the  task  with  which  all  were  dealing. 

2.  PUBLICITY  AND  EDUCATIONAL  MEASURES. 

In  Agricola  village  there  were  1,335  people  who  had  never 
heard  of  Ankylostomiasis.  They  were  to  be  informed  about  the 
disease  and  to  become  so  interested  in  it  that  they  would  vol- 
untarily submit  themselves  for  examinations,  and  be  willing, 
if  found  infected,  to  take  treatment  until  cured. 

Announcements  of  our  selection  of  this  village,  as  the  first 
point  of  attack,  were  made  in  the  daily  papers  of  Georgetown. 
Here  also  were  set  forth  a  statement  of  our  purposes,  of  the 
symptoms  of  the  disease  and  methods  of  contracting  it,  of  the 
ease  with  which  it  could  be  cured,  and  of  the  beneficial  results 
of  treatment. 

Sheets  containing  the  foregoing  information  were  printed  and 
scattered  throughout  the  area,  with  the  additional  statement 
that  when  Agricola  should  become  free  from  the  disease,  other 
villages  along  the  east  bank  would  be  served  in  like  manner, 


6  THK  ERADICATION   O^  HOOKWORM   DISEASE. 

if  they  so  desired.  It  was  arranged  to  have  some  notice  of  the 
work  appear  once  or  twice  a  week  in  the  daily  papers  of  George- 
town, these  notices  being  printed  free  of  charge. 

The  opening  lecture  on  Ankylostomiasis  was  arranged  for, 
special  seats  being  reserved  for  His  Excellency,  the  Governor, 
the  Medical  Officers  of  the  Colony,  heads  of  Government  de- 
partments, the  two  resident  Bishops,  the  clergy  of  Georgetown 
and  the  near-by  villages,  plantation-owners  and  managers, 
village  officials,  and  school-teachers,  all  of  whom  were  especially 
invited.  The  attendance  was  far  beyond  the  capacity  of  the 
building. 

The  speaker  was  introduced  by  Surgeon-General  Godfrey, 
and  delivered  a  lecture  on  Ankylostomiasis.  The  magic- 
lantern,  with  the  usual  complement  of  slides,  was  used,  and  in  a 
general  way  it  was  shown  how  we  hoped  to  serve  the  best  inter- 
ests of  the  people  by  treating  them  and  curing  them  of  the 
disease.  Several  typical  examples  were  shown  to  the  audience 
at  the  conclusion  of  the  lecture.  Dr.  J.  E.  A.  Ferguson,  District 
Medical  Officer,  also  presented  a  number  of  interesting  cases, 
bringing  out  forcibly  the  intimate  relationship  between  Ankylos- 
tomiasis and  the  maternal  death-rate  at  childbirth. 

Following  these  demonstrations,  Surgeon-General  Godfrey 
pledged  us  the  hearty  support  of  the  Medical  and  Sanitary 
Departments  of  the  Colony.  His  Excellency,  the  Governor, 
Sir  Walter  Edgerton,  spoke  very  favorably  of  the  campaign, 
expressing  his  gratitude  for  the  help  given  by  the  International 
Health  Commission,  and  at  the  close  of  his  remarks  proposed  a 
vote  of  thanks  to  the  Commission  and  their  representative, 
which  met  with  a  hearty  response  from  the  audience. 

The  presence  of  the  Governor-General,  the  Surgeon-General, 
the  prominent  officials,  the  Bishops,  the  clergy  and  many  others 
of  wide  influence,  necessarily  gave  the  campaign  a  great  impetus. 

Other  lectures  were  delivered  at  the  schools  of  Agricola,  and 
throughout  the  area,  and  one  lecture  especially  for  those  who 
were  unable  to  secure  seats  or  standing-room  at  the  opening 
lecture.  Other  informal  talks  were  made  at  the  Dispensary, 
illustrated  from  time  to  time,  with  the  hookworm  chart,  and  the 
ova  and  live  embryos  were  shown  under  the  microscope. 

As  the  work  progressed  it  became  necessary  for  the  Medical 
Officer  to  call  in  person  on  a  number  of  the  villagers  and  per- 


C]eNSUS  TAKING.  7 

suade  them  to  co-operate,  explaining  to  them  that  our  sole 
desire  was  to  render  them  a  service  without  any  cost  to  them. 

To  secure  publicity  for  the  campaign,  and  to  educate  the 
people  concerning  Ankylostomiasis,  our  efforts  were  directed 
through  the  following  channels: 

1.  (Through  local  papers.)  Articles  dealing  with  Ankylos- 
tomiasis in  a  simple  way;  that  is,  detailing  its  symptoms,  its 
harmful  effects,  its  prevalence,  the  methods  of  examination, 
the  nature  of  treatment,  the  certainty  of  speedy  cure,  place  and 
time  of  free  examination,  etc.,  were  furnished  to  the  local  press, 
and  also  printed  in  sheet  form  and  distributed  throughout  the 
District. 

2.  Statements  from  medical  authorities  and  Government 
officials  endorsing  the  work  and  asking  for  the  cooperation  of  the 
people  were  secured  and  given  wide  publicity. 

3.  Illustrated  lectures  were  delivered  wherever  a  sufficient 
number  of  people  could  be  assembled.^ 

4.  Special  literature  on  Ankylostomiasis  illustrated  with  cuts 
showing  cases  before  and  after  treatment,  etc.,  were  distributed 
freely.^ 

5.  The  co-operation  of  village  authorities,  schoolmasters, 
clubs,  Baby-Saving  Leagues,  and  Church  organizations,  was 
secured  and  every  worthful  kind  of  local  influence  was  enhsted 
in  the  campaign.  The  pastors  of  the  churches  and  the  school- 
masters were  especially  helpful. 

3.  CENSUS  TAKING. 

In  order  to  make  effective  any  plan  for  the  complete  eradica- 
tion of  Ankylostomiasis,  the  first  steps  are  to  secure  a  complete 
and  correct  census  embracing  all  individuals  within  the  field 
of  operation;  to  record  the  personal  history  of  each  as  to  name, 
race,  sex  and  age;  and  to  number  or  mark  each  house  so  that 
these  individuals  may  be  located  at  any  time. 

This  in  itself  is  a  considerable  undertaking,  and  was  made 
more  difficult  in  Peter's  Hall  District  by  the  dense  crowding 
of  the  people  in  some  of  the  villages,  and  their  tendency  to  shift 
and  move  about,  many  of  them  not  having  a  permanent  place 
of  abode. 

To  take  the  census  it  was  necessary  to  have  men  who  could 
write  legibly  and  who  possessed  some  clerical  ability.     Under 

^Charts  for  this  purpose  dealing  with  Ankylostomiasis  can  be  had  from 
the  International  Health  Commission  at  Washington,  D.  C.  Through  it 
also  can  be  purchased  a  variety  of  magic-lantern  slides  dealing  with  the 
same  subject,  which  can  be  used  to  advantage  in  night  lectures. 

^The  half-tones  suitable  for  illustrations  may  be  secured  through  the 
offices  of  the  Commission. 


8  THE  ERADICATION   OF  HOOKWORM  DISEASE. 

the  Chapter  on  "Personnel  of  Force"  it  is  provided  that  there 
shall  be  a  male  nurse  and  one  assistant  to  each  1,200  inhabitants, 
for  the  purpose  of  administering  the  thymol.  When  the  nurses 
and  their  assistants  were  employed  care  was  taken  that  they 
should  possess  the  qualifications  necessary  to  census-takers, 
since  it  was  not  only  economy  to  have  them  thus  employed, 
before  the  actual  treatment  of  cases  began,  but  it  afforded  them 
an  opportunity  to  get  acquainted  with  the  people. 

Bach  group  of  census- takers  consisted  of  three  people.  Two 
of  these  went  together  from  house  to  house,  recording  names 
and  personal  history,  inspecting  latrines,  numbering  the  houses, 
and  delivering  to  each  individual  a  properly  marked  tin  con- 
tainer,^ requesting  that  a  small  portion  of  the  feces  should  be 
placed  therein.  On  the  following  day  the  third  man  of  the 
group  called  to  collect  these  specimens  and  to  take  them  to  the 
central  office  for  microscopic  examination. 

We  found  that  it  is  best  in  the  villages  to  take  the  houses 
street  by  street,  numbering  them  consecutively,  for  which  pur- 
pose a  heavy  red  oil  crayon  answers  admirably.  Form  No.  i 
in  the  Appendix  shows  a  sample  page  of  the  field  census-book 
used  in  British  Guiana.  These  books  provide  for  200  names, 
approximately  one  day's  work  in  census-taking.  This  arrange- 
ment allows  the  book  to  be  handed  in  complete  at  the  end  of 
each  day  to  be  recorded,  and  also  makes  the  names  at  once 
available  for  the  use  of  the  collector  in  gathering  specimens  for 
examination. 

Each  day  after  the  containers  had  been  given  out,  the  col- 
lectors in  our  work  in  British  Guiana  were  able  to  secure  about 
f  of  the  desired  specimens  due.  They  were  required  to  keep  a 
list  of  the  remaining  J  who  were  delinquent,  and  to  call  from  time 
to  time  until  specimens  were  obtained  from  every  individual. 

4.  MICROSCOPIC  EXAMINATION. 

After  the  specimens  of  feces  had  been  collected  by  the  third 
man  in  the  census  group  and  had  been  brought  to  the  dispensary, 
they  were  assorted  with  reference  to  the  several  villages  from 
which  they  had  been  brought  and  were  then  ready  for  micro- 
scopic examination.  The  microscopist  was  required  to  record 
the  data  appearing  on  the  paper  cover  of  each  box  before  remov- 

^A  one-fourth  ounce  container  with  paper  inserted  in  the  lid  may  be  had 
from  the  Myers  Manufacturing  Company,  Camden,  N.  J.,  U.  S.  A.  They  are 
inexpensive  and  in  general  use  for  this  purpose. 


MICROSCOPIC   EXAMINATION.  9 

ing  the  cover,  thus  preventing  confusion.  The  form  used  for 
the  microscopical  record  sheet  is  shown  in  the  Appendix. 

The  method  of  examination  used  in  British  Guiana  and  recom- 
mended is  that  detailed  in  Dock  and  Bass  Hookworm  Disease, 
pages  158-16 1.     Briefly  stated,  it  is  as  follows: 

One-  by  three-inch  slides  were  used.  Place  two  or  three  drops 
of  water  in  the  center  of  the  slide  and  with  a  wooden  toothpick 
take  up  a  quantity  of  feces  about  the  size  of  the  head  of  a  match. 
Stir  this  into  the  water  on  the  slides  until  it  is  cloudy,  spreading 
out  the  diluted  feces  over  the  surface  of  the  slide  at  the  same  time 
Care  should  be  taken  not  to  get  the  mixture  too  thick  to  allow 
rapid  examination  and  clear  outlines.  Should  the  first  slide 
prove  negative  another  is  prepared  in  the  same  way.  No 
examination  is  recorded  as  negative  until  three  slides  have  been 
examined^  all  failing  to  show  the  presence  of  the  Ankylostoma 
ova. 

No  cover  glass  is  necessary.  Only  wet  preparations  should  be 
examined.  A  properly  prepared  specimen  can  be  gone  over 
thoroughly  before  drying  out.  The  two-third  objective  and 
1"  eye-piece,  or  the  i6  millimeter  objective  and  corresponding 
eye-piece  will  give  the  proper  magnification  of  about  loo  diame- 
ters. It  is  well  to  have  the  one-sixth  objective  also  for  demon- 
stration and  differentiation  of  doubtful  ova.  The  mechanical 
stage  is  not  essential  and  not  commonly  in  use  in  the  work  in  the 
United  States.  That  degree  of  skill  is  readily  acquired  which 
enable  the  microscopist  to  manipulate  the  slide  with  the  fingers. 
When  this  method  of  examination  is  used  more  than  loo  people 
can  be  examined  daily  by  each  microscopist. 

Recently  there  has  been  put  upon  the  market  by  Bausch  and 
Lomb,  of  Rochester,  New  York,  a  specially  constructed  centri- 
fuge^ which  greatly  simplifies  the  work  of  the  microscopist  and 
at  the  same  time  secures  greater  accuracy.  This  is  a  hand-drive 
machine  with  a  Stewart  Pan-Head  carrying  20  tubes.  These 
tubes  are  of  glass,  open  at  both  ends,  providing  for  the  use  of 
ordinary  corks  of  the  proper  size.  A  piece  of  the  feces  about  the 
size  of  a  bean  is  placed  in  an  ordinary  test  tube  and  agitated 
with  sufficient  water.  When  in  solution  this  is  strained  through 
coarse  gauze  into  the  centrifuge  tube  in  order  to  remove  large 
debris.     The  centrifuge  tube  is  then  corked  and  placed  in  posi- 

^Since  these  special  centrifuges  and  supplies  are  not  yet  listed  in  the 
catalogues,  a  descriptive  list  will  be  found  in  the  Appendix. 


lO  THE  ERADICATION   OF  HOOKWORM  DISEASE. 

tion.  Gummed  labels  are  used  on  both  the  flat  bottom  and 
centrifuge  tubes,  with  numbers  corresponding  to  the  numbers 
given  to  the  names  of  the  individuals  on  the  record  sheets,  thus 
avoiding  danger  of  confusing  specimens.  The  tubes  and  ftm- 
nels  are  easily  boiled  and  the  corks  discarded  after  use.  After 
the  specimen  is  centrifuged  all  suspended  debris  (including  all 
ova)  is  found  deposited  on  the  cork  at  the  outer  end  of  the 
tube.  This  is  removed  and  the  deposit  is  smeared  on  a  2  x  3" 
slide  on  which  have  been  previously  placed  several  drops  of 
water.  This  mixture  is  uniformly  spread  over  the  surface  of  the 
slide  and  examined  and  with  a  two-third  objective  and  1"  eye- 
piece without  cover  glass  or  mechanical  stage.  The  process  is 
rapid  and  is  facilitated  by  having  one  or  two  cheap  employees 
in  the  central  office  to  do  the  centrifuging. 

When  the  centrifuge  is  not  used,  it  has  been  customary,  as 
we  have  seen,  to  examine  three  slides,  before  recording  negative 
results.  It  is  only  necessary  to  examine  one  slide,  however, 
with  the  centrifuge  method  and  more  accurate  results  are  ob- 
tained. Especially  is  the  use  of  the  centrifuge  valuable  in  the 
re-examinations  after  treatment,  where  the  eggs  are  often 
reduced  to  the  minimum. 

The  method  adopted  in  British  Guiana,  of  cleaning  the  micro- 
scope slides  after  use,  was  simple,  time-saving,  and  effective. 
Immediately  after  use  they  were  dropped  into  a  bowl  containing 
a  strong  solution  of  Jeyes  Fluid  or  Lysol.  At  the  close  of  the 
day's  work  they  were  stirred  about  in  this  bowl  until  all  particles 
of  fecal  matter  were  detached;  then  they  were  removed,  thor- 
oughly rinsed  through  several  waters,  and  wiped  dry.  The  tin 
containers  and  toothpicks  were,  of  course,  discarded  after  use. 

In  British  Guiana,  in  a  district  of  14,000  inhabitants,  three 
young  East  Indians  were  found  sufficient  to  do  the  microscopi- 
cal work.  Previous  experience  with  the  microscope  was  not 
found  to  be  essential.  After  several  weeks  of  training  these 
men  were  examining  from  100  to  125  specimens  daily,  and  this 
number  should  be  materially  increased  with  further  experience. 

5.  TREATMENT. 

The  purpose  of  the  campaign  in  British  Guiana  was  primarily, 
of  course,  to  eradicate  Ankylostomiasis,  but  in  doing  this  we 
w^re  to  test  two  methods  of  administering  the  thymol : 


Treatment.  it 

1.  The  "  Daily"  method,  which  had  been  successfully  used  by 
Dr.  J.  B.  A.  Ferguson  in  treating  the  indentured  East  Indian 
laborers  on  the  sugar  estates  of  Peter's  Hall  District;  and, 

2.  The  "Intensive"  method,  which  had  been  used  almost 
exclusively  in  the  United  States,  in  the  extensive  campaign 
waged  against  Hookworm  Disease  in  the  Southern  States. 

The  "Daily"  method  of  treatment,  as  it  was  employed  in 
British  Guiana,  required  that  the  adult  patient  be  given  lo 
grains  of  thymol  each  day,  except  Sunday,  for  four  months,  or 
approximately  loo  doses.  No  purgative  was  necessary  and  no 
modification  of  diet  or  habits  was  required,  except  abstention 
from  alcoholics  for  a  few  hours  after  the  thymol  was  taken. 

As  rapidly  as  the  villages  in  Area  B — five  in  number — could 
be  examined  microscopically,  those  found  infected  were  placed 
on  the  "Daily"  treatment.  This  Area  had  a  population  of 
3,563,  of  whom  3,207  were  examined,  showing  1,918  to  be  in- 
fected with  Ankylostomiasis. 

The  thymol-distributors  were  accompanied  by  the  Supervising 
Medical  Officer  on  their  first  visit  to  each  patient,  and,  later, 
certain  days  were  appointed  for  each  village  when  he  visited  all 
malcontents  and  could  be  consulted  by  the  patients.  This 
practice  established  a  bond  of  sympathy  and  understanding 
between  the  Medical  Officer  and  the  people,  which  insured  more 
perfect  co-operation  throughout  the  campaign. 

It  was  not  found  difficult  to  induce  most  of  those  infected  to 
begin  treatment.  Many  of  them  were  eagerly  responsive  to  the 
idea  of  "getting  something  for  nothing,"  and  all  seemed  to  covet 
the  little  cards,  or  "Certificates  of  Health,"  which  were  issued 
to  those  not  infected  with  Ankylostomiasis,  and  promised  to 
those  who  would  persist  in  the  treatment  until  cured. 

Of  the  several  elements  of  population  dealt  with,  the  East 
Indians,  who  compose  approximately  half  of  the  population, 
were  the  most  docile  and  easily  managed. 

The  fact  that  this  method  of  treatment  did  not  require  the 
patient  to  make  any  sacrifice  in  diet,  or  habits,  was  a  persuasive 
talking-point  in  inducing  the  infected  to  begin  treatment,  but 
this  advantage  was  more  than  lost  when  it  was  learned  that  a 
dose  of  thymol  was  to  be  given  them  daily  for  the  long  period  of 
four  months.  It  was  from  the  prolongation  of  treatment  that 
most  of  our  difficulties  with  this  method  arose.  A  considerable 
number  became  tired  of  the  daily  dose  and  were  inclined  to 


12  1  TH^  ERADICATION   OF  HOOKWORM  DISEAS]^. 

abandon  treatment,  the  improvement  in  physical  condition 
being  so  slow  that  it  was  often  not  recognized  sufficiently  to 
encourage  them  to  continue.  During  the  period  of  four  months 
there  were  often  interruptions  in  the  course  of  treatment  by 
unavoidable  circumstances — absence  from  home,  intercurrent 
illness,  etc. — and  since  its  efficacy  seems  to  depend  largely  upon 
its  regularity,  this  added  to  the  difficulties. 

The  rather  elaborate  force  required  for  the  distribution  of  the 
daily  doses  of  thymol — one  distributor  to  each  200  patients — 
made  it  necessary  to  recruit  this  force  from  a  low-salaried 
source — $8.00  to  $10.00  per  month — and  it  was  very  difficult 
to  secure  trustworthy  people  at  this  price. 

The  constant  demand  made  upon  the  time  of  the  Supervising 
Medical  Officer  to  see  the  dissatisfied  and  persuade  them  to 
continue  the  treatment  was  so  heavy  that  it  would  materially 
limit  the  Area  or  population  which  could  be  handled  by  one  such 
officer. 

After  the  treatment  was  well  under  way,  in  Area  B.,  the  Vil- 
lage of  Meadow  Bank  was  selected  and  placed  under  treatment 
by  the  "Intensive"  method. 

This  village,  with  a  population  of  520,  had  an  infection  of 
52!  per  cent  or  275.  The  "  Intensive"  method  of  treatment,  as 
employed  here,  provides  that  the  adult  be  given  40  to  60  grains 
of  powdered  thymol  on  one  day  in  each  week  until  cured. 
This  dose  of  thymol  is  preceded  and  followed  by  an  active  saline 
purgative,  and  the  patient  is  required  to  abstain  from  food  for 
at  least  18  hours  during  the  treatment.  It  has  been  found  that 
better  results  are  obtained  if  the  thymol  is  finely  powdered  and 
triturated  with  from  |  to  an  equal  quantity  of  sugar  of  milk,  and 
given  in  a  cachet  or  gelatin  capsule.  It  may  be  of  interest 
to  give  in  detail  the  method  used  in  administering  the  thymol  by 
the  intensive  method. 

DIRECTIONS. 

1.  On  the  day  preceding  the  treatment  give  a  large  dose  of 
sulphate  of  magnesia  at  5  p.  m.  No  supper  should  be  eaten. 
The  saline  should  thoroughly  empty  the  alimentary  canal. 

2.  Remain  in  bed  the  following  morning  without  food. 

3.  At  6  a.  m.,  take  one-half  of  the  thymol;  at  8  a.  m.,  take  the 
remainder. 


Treatment.  13 

4.  Take  a  large  dose  of  sulphate  of  magnesia  at  1 1  a.  m.  This 
should  be  repeated  if  a  thorough  movement  of  the  bowels  is  not 
secured  within  two  hours. 

5.  No  food  should  be  taken  until  after  the  bowels  have  moved 
thoroughly,  and  then  no  greasy  foods,  milk,  alcoholics  or  malt 
drinks  should  be  indulged  in. 

6.  The  usual  diet  and  habits  may  be  resumed  on  the  day 
following  treatment. 

7.  If  the  patient  feels  weak  or  dizzy  during  the  treatment 
give  one-half  cup  of  strong  coffee  without  sugar  or  milk. 

8.  Careful  examination  of  the  dejecta  from  the  second  dose 
of  sulphate  of  magnesia  should  show  the  dead  worms  expelled. 

9.  Several  of  these  courses  of  thymol  given  at  weekly  intervals 
are  usually  necessary  for  cure.  (See  form  of  printed  directions 
in  Appendix.) 

There  is  a  scientific  reason  behind  each  step  of  the  treatment  as 
detailed  by  these  directions,  which  must  be  evident  to  the  mind 
of  the  medical  man  who  is  familiar  with  the  disease.  Since 
Ankylostomiasis  is  a  disease  which  will  not  yield  to  haphazard 
medication,  many  cases  proving  obstinate  under  any  methods 
of  treatment,  and  since  thymol  is  a  drug  which  must  be  given 
under  certain  restrictions  in  order  to  be  safe  and  efficient,  it 
is  well  to  have  definite  directions  to  follow  in  its  administration. 

More  than  50  per  cent  of  our  cases  were  cured  in  British 
Guiana  with  two  treatments,  or  in  eight  days  after  the  first 
examination.  A  very  small  per  cent  required  more  than  three 
treatments.  Almost  any  person  who  is  convinced  that  the 
Ankylostome  is  present  in  his  or  her  body  will  readily  consent 
to  give  one  day  out  of  each  week  for  two  or  three  weeks  to  be 
cured  of  this  malady.  Thousands  of  working-people,  miners, 
carpenters,  farmers,  and  clerks,  have  been  treated  on  Sundays, 
thus  losing  no  time  from  their  labors. 

It  has  been  repeatedly  stated  that  the  above-mentioned  dose 
of  thymol  is  "dangerous."  In  reply  to  this  I  will  point  to  the 
fact  that  more  than  a  million  maximum  doses  of  thymol  have 
been  administered  in  the  United  States  to  persons  of  every 
age,  color,  race,  and  physical  condition,  and  that  most  of  these 
treatments  were  taken  by  the  patients  in  their  own  homes  with- 
out supervision  from  nurse  or  physician,  and  yet  without  a 
fatality,  or  serious  physical  disturbance,  except  in  a  very  limited 


H 


the;  eradication  of  hookworm  disease. 


number  of  cases  where  the  patients  indulged  in  alcoholic  drinks 
with  the  thymol  still  in  the  intestinal  canal. 

Further,  it  is  evident  that  in  a  large  number  of  cases  the 
thymol  was  incorrectly  taken,  for  many  of  these  people  were 
illiterate  and  densely  ignorant.  I  fancy  there  are  but  few  drugs 
in  the  Pharmacopoeia  which  could  stand  so  severe  a  test,  and 
still  be  considered  comparatively  safe. 

At  the  end  of  this  chapter  is  given  a  complete  report  of  the 
campaign  in  Meadow  Bank  with  the  "Intensive"  method,  and 
a  partial  report  from  Agricola  village,  where  the  campaign  with 
the  "  Daily"  method  of  treatment  is  drawing  to  a  close. 

Our  experience  in  British  Guiana  with  the  two  methods  of 
treatment  demonstrates  the  fact  that — 

1.  The  "Intensive"  treatment  presents  less  difficulty  as  an 
administrative  problem. 

2.  It  cures  a  larger  percentage  of  those  infected. 

3.  These  cures  are  secured  at  a  smaller  per  capita  cost. 

For  the  foregoing  reasons  only  the  patients  in  the  first  Area 
of  Peter's  Hall  District  will  be  treated  by  the  "Daily"  method, 
in  all  other  Areas  the  "  Intensive"  treatment  will  be  employed. 

From  Report  of  August  15,  IQ14. 


Agricola. 

Meadow  Bank. 

Method  of  treatment  used 

Daily. 
I3I  months. 
1,210 

635(52%) 

3620 

{') 

{') 
78(11%) 
(') 

2 
303  (49%) 
236 

0 

Intensive 

Duration  of  campaign 

^2  months 

Population  examined 

520 

275  (52f  %) 
211 

Number  infected  with  Ankylostomes 

Number  beginning  treatment 

Number  refusing  treatment  without  cause .  . 

Number  to  whom  treatment  was  refused  for 

medical  reasons 

7 
^15 
2  Qess  than 

Number  abandoning  treatment,  some   re- 
maining and  others  removing 

Number  removing  before  treatment  started 
Number  remaining  to  be  treated . 

1%). 
^34 
240 

I 

Number  died  (not  associated  with  adminis- 
tration of  thymol) 

Number  cured 

209  (87f  %) 
0 

Under  treatment. . . 

Unaccounted  for 

7 

^Campaign  not  complete.  ^Campaign  complete.  ^Figures  not  available, 
or  not  verified.  *For  medical  reasons:  pregnancy,  8;  lunacy  3;  chronic 
dysentery,  I ;  chronic  diarrhoea  and  "old  age,"  2;  biliary  cirrhosis,  i. 
^These  removals  were  due  in  the  main  to  the  rigid  enforcement  of  sanitary 
regulations. 

The  campaign  was  unduly  prolonged  by  church  festivals  and 
sanitary  work  in  progress  in  the  village. 


RK-KXAMINATION.  1 5 

6.  RE-EXAMINATION. 

As  complete  eradication  aims  at  writing  "  cured''  after  the 
name  of  every  infected  individual  in  the  Area  of  Operation, 
re-examination  after  treatment  to  ascertain  who  are  "cured" 
is  an  important  step  in  the  campaign,  and  the  methods  used 
should  be  such  as  to  insure  unquestioned  accuracy  in  the  results. 
Our  experience  in  British  Guiana  shows  that  certain  general, 
but  none  the  less  essential,  rules  should  be  followed : 

1.  No  negative  results,  or  "cures,"  were  accepted  as  such 
unless  the  specimen  of  feces  was  secured  at  least  six  days  after 
the  last  dose  of  thymol  was  given  to  the  patient.  This  pre- 
caution is  rendered  necessary  from  the  fact  that  the  toxic  effect 
of  the  thymol  on  the  female  Ankylostome  continues  for  some 
days  after  its  administration  to  the  host,  during  which  time 
the  absence  of  ova  will  be  misleading.  This  applies  to  the  use 
of  the  small  daily  dose  as  well  as  the  much  larger  dose  of  thymol 
used  in  the  "Intensive"  treatment.  The  use  of  a  specially 
constructed  centrifuge  accomodating  twenty  specimens,  and 
operated  by  hand,  which  can  be  had  in  the  American  markets, 
will  greatly  facilitate  this  state  of  the  work. 

2.  Re-examinations  with  the  daily  small  dose  method  were 
made  at  the  end  of  the  third  month,  and  monthly  thereafter 
until  negative  results  were  obtained.  Each  time  the  patient 
was  required  to  omit  the  thymol  a  week  prior  to  examination. 

3.  Re-examinations  with  the  "  Intensive"  method  of  treatment 
were  made  on  the  sixth  day  after  the  second  weekly  treatment, 
and  weekly  thereafter  until  the  patient  was  cured.  This 
arrangement  permits  the  patient  to  have  treatment  on  the  same 
day  of  each  week,  and  yet  allows  a  sufficient  interval  between 
the  examination  and  the  last  dose  of  thymol. 

4.  It  is  recognized  that  there  is  a  possibility  of  error  in  a 
small  percentage  of  cases  if  the  negative  results  of  one  examina- 
tion are  accepted  as  final.  This  possibility  of  error  arises 
from  the  fact  that,  while  the  feces  of  a  patient  may  show 
no  ova  at  the  time  of  examination,  there  can  be  numerous 
Ankylostome  embryos  in  the  tissues  of  the  body,  en  route  to 
the  intestinal  canal,  as  a  result  of  a  recent  skin  infection.  Some 
weeks  must  elapse  before  these  worms  can  reach  the  intestinal 
canal,  grow  to  adult  size,  and  begin  to  ovulate.  Only  repeated 
examinations,  at  intervals,  as  long  as  there  is  possibility  of 
infection,  will  eliminate  these  cases. 

It  is  obvious  to  anyone  with  laboratory  experience  that  the 
use  of  the  centrifuge  will  secure  much  more  accurate  results  than 
those  reached  without  it,  and  this  is  especially  true  in  cases  of 
mild  infection,  and  partially  cured  cases  met  with  in  re-exam- 


1 6  THE   ERADICATION   OF  HOOKWORM  DISEASE. 

ination,  where  the  numbers  of  ova  are  reduced  to  a  minimum. 
Centrifuges  operated  by  hand  are  usually  constructed  to  handle 
2  or  4  specimens,  with  tubes  of  such  shape  as  to  render  it  difficult 
to  sterilize  them.  To  attempt  to  use  an  instrument  of  this  type 
means  a  great  loss  of  time.  It  was  to  meet  our  needs  that  the 
specially  constructed  centrifuge  rnentioned  in  a  preceding  chap- 
ter (6.  Microscopic  Examinations,  page  9),  was  offered. 

This  instrument  accommodates  20  specimens.  The  tubes  are 
plain  glass,  open  at  both  ends,  and  can  be  quickly  sterilized  by 
boiling.  Its  use  not  only  secures  greater  accuracy,  but  also 
greater  speed  in  making  the  examinations. 

7.  WORKING  FORCE. 

In  the  beginning  of  the  work  in  Peter's  Hall  District  the  force 
consisted  of  one  Black,  who  had  some  training  in  sanitation, 
and  the  Representative  of  the  International  Health  Com- 
mission. There  were  no  additions  made  to  the  force  until  the 
publicity  work  was  done,  when  there  were  added  two  young 
East  Indians  as  Microscopists,  and  a  colored  man  as  Pioneer. 
With  these  additions,  the  taking  of  the  census  began.  Thus 
at  each  successive  step  of  the  campaign  the  force  was  developed 
and  added  to,  and  methods  carefully  tested  out,  until  we  recog- 
nized a  definite  personnel  adapted  to  a  definite  programme, 
and  able  to  carry  it  out  economically,  thoroughly,  quickly,  and 
efficiently.  The  following  statement  indicates  the  force  em- 
ployed for  Peter's  Hall  Medical  District : 

One  Supervising  Medical  Officer,  salary  $1,600.00;  one  Chief 
Clerk,  salary  $65.00  to  $80.00  per  month;  one  assistant  Clerk, 
salary  $20.00  to  $30.00  per  month;  three  Pioneers, salary  $15.00 
to  $20.00  per  month,  each. 

To  each  1,200  inhabitants:  one  Male  Nurse,  salary  $30.00 
to  $40.00  per  month;  one  Assistant  Nurse,  salary  $8.00  to 
$12.00  per  month. 

To  every  4,000  or  5,000  inhabitants:  One  Microscopist, 
salary  $20.00  to  $30.00  per  month. 

The  male  nurse  referred  to  above  was  usually  an  East  Indian 
or  Black  who  had  seen  service  either  in  the  Government  Hos- 
pitals or  those  of  the  sugar  estates.  Whenever  possible,  these 
men  were  secured  in  the  district  where  they  were  to  work. 
Their  service  in  the  hospitals  had  given  them  a  certain  amount 
of  prestige  in  the  minds  of  the  people,  who  readily  accepted  their 


FiNANCIAIv   PROCEDURE.  1 7 

services  in  giving  the  thymol  treatment.  The  nurse  and  his 
assistant  took  the  census  in  the  beginning  of  the  work,  and  col- 
lected the  specimens  of  feces  for  examination. 

When  the  time  came  for  giving  the  treatment  the  nurse  and 
his  assistant  were  furnished  with  a  treatment  book  (see  form  in 
Appendix),  in  which  were  recorded  the  names  of  all  who  had 
Ankylostomiasis.  These  people  were  seen  in  their  homes,  and 
arrangements  were  made  with  each  individual  as  to  the  day  of 
the  wxek  on  which  he  or  she  preferred  to  take  treatment.  It 
was  found  that  a  nurse  could  handle  about  50  cases  each  day, 
and  his  assistant  the  same. 

These  men  called  at  the  homes  of  the  patients  on  the  after- 
noon of  the  day  before  the  treatment,  administered  the  pre- 
liminary purge,  and  gave  directions  about  fasting,  etc.  On  the 
following  morning  they  went  from  house  to  house,  giving  the 
thymol  and  keeping  the  patients  under  observation.  At  1 1  a.  m. 
they  gave  to  each  patient  the  last  saline  purge  and  saw  that  it 
acted  thoroughly  before  they  allowed  the  patient  to  eat  or  to 
leave  his  premises. 

One  week  later  the  patients  received  their  second  treatment, 
given  in  the  same  way,  and  each  successive  week  until  cured. 
The  nurse  and  his  assistant  are  expected  to  secure  specimens  for 
re-examination  from  patients  who  have  had  two  treatments,  at 
least  six  days  after  the  last  treatment,  and  to  bring  them  into  the 
office  weekly  thereafter  until  they  are  found  cured.  This  phase 
of  the  work  must  be  watched  carefully  to  prevent  confusion. 

Should  the  "Daily"  method  of  treatment  be  used,  some 
changes  in  the  above-mentioned  force  would  be  necessary. 

The  Medical  Officer,  Chief  Clerk,  Assistant  Clerk,  and  Micro- 
scopist  would  remain  the  same,  but  there  would  be  a  Pioneer  to 
each  3,500  inhabitants,  and  a  Distributor  of  thymol  to  each  200 
infected  cases.  These  Distributors  may  be  had  at  an  average 
salary  of  $8.00  to  $10.00  per  month. 

8.  FINANCIAL  PROCEDURE. 

I.  Following  the  visit  of  Mr.  Wickliffe  Rose,  Director-General 
of  the  International  Health  Commission  to  British  Guiana,  in 
the  autumn  of  19 13,  on  which  occasion  offers  of  assistance  in  the 
eradication  of  Ankylostomiasis  were  made  to  that  Colony,  a 
budget  was  prepared  by  the  Surgeon-General  providing  for 


1 8  THE   ERADICATION   OF  HOOKWORM   DISEASE. 

eradication  work  in  a  definite  territory — Peter's  Hall  District — 
during  one  year.  This  budget  was  submitted  to  the  Inter- 
national Health  Commission,  and  adopted.  Following  their 
approval  of  the  budget,  that  portion  of  the  funds  to  be  furnished 
by  them  was  paid  through  the  Receiver-General  into  the  Gov- 
ernment treasury  in  quarterly  installments,  and  disbursed 
through  the  same  channels,  and  under  the  same  restrictions 
as  control  Government  expenditures. 

2.  It  was  understood  that  these  funds  were  to  be  made  avail- 
able by  submitting  to  the  Surgeon-General  of  the  Colony  a 
written  and  itemized  requisition,  signed  by  the  Supervising 
Medical  Officer  of  the  Eradication  Campaign,  and  the  Govern- 
ment Medical  Officer  of  the  District  where  operations  were  in 
progress.  These  requisitions  were  countersigned  by  the 
Surgeon-General  and  forwarded  to  the  Treasury,  where  payment 
was  made  at  the  end  of  each  month.  The  same  procedure 
applied  to  all  invoices  and  itemized  bills. 

3.  It  was  agreed  that  all  vouchers  should  be  made  out  in 
triplicate,  so  that  a  copy  might  be  supplied  to  the  Receiver- 
General,  the  Treasury  Department,  and  the  International  Health 
Commission. 

4.  A  copy  of  the  budget  under  which  he  was  operating  was 
supplied  to  the  Supervising  Medical  Officer  and  it  was  agreed 
that,  at  all  times,  expenditures  must  be  kept  within  the  amounts 
allotted  to  each  head  or  item  of  the  budget. 

5.  A  separate  account  was  kept  for  each  budget  in  operation, 
both  by  the  Surgeon-General's  office  and  by  the  Chief  Clerk  of 
the  force. 

6.  At  the  month's  end  a  statement  of  expenditures  under 
each  budget  was  prepared  by  the  Chief  Clerk  and  compared  with 
the  accounts  being  kept  in  the  Surgeon-General's  office. 

7.  A  Quarterly  Report  of  Expenditures  in  each  area  was  pre- 
pared in  the  Surgeon-General's  office  and  sent  to  the  Inter- 
national Health  Commission,  together  with  the  usual  Quarterly 
Report  of  work  done. 

8.  It  was  agreed  that  a  report  of  the  auditing  of  the  funds 
furnished  by  the  International  Health  Commission  should  be 
sent  them  from  the  Auditing  Department  of  the  Government 
semi-annually. 


SANITARY   MEASURES  FOR  PREVENTION.  1 9 

9.  DURATION  OF  CAMPAIGN. 

With  the  "Intensive"  method  of  treatment  50  per  cent  of 
the  cases  treated  in  Meadow  Bank  Village,  British  Guiana,  were 
cured  in  two  weeks;  that  is,  they  were  examined,  found  to  be 
infected  and  given  the  first  treatment  at  once ;  a  week  later  they 
were  given  the  second  treatment;  and  six  days  later  they  were 
re-examined  and  found  cured.  35  per  cent  were  cured  with  three 
treatments,  which  required  three  weeks;  and  15  per  cent 
required  from  four  to  six  treatments,  consuming  a  maximum 
time  of  six  weeks.  In  actual  experience  all  infected  cases  in  a 
given  territory  can  not  be  put  on  treatment  simultaneously. 
With  the  force  provided  for  in  the  preceding  pages,  making  due 
allowance  for  contingencies,  the  campaign  in  a  given  territory 
should  be  completed  in  four  months  from  its  inauguration, 
whenever  the  "Intensive"  method  of  treatment  is  used.  The 
campaign  in  Meadow  Bank  Village  was  completed  in  two 
months,  from  which  fact  it  may  be  seen  that  the  above  estimate 
allows  for  twice  the  time  required  in  actual  experience. 

With  the  "Daily"  method,  four  months  are  required  for  the 
treatment  of  the  individual  case.  Recent  reports  from  British 
Guiana  indicate  that  50  per  cent  are  cured  in  three  months; 
but  we  can  not  yet  be  certain  how  long  it  may  take  to  cure  the 
remaining  50  per  cent.  Present  information  indicates  strongly 
that  the  campaign  in  Area  B,  Peter's  Hall  District,  where  the 
"  Daily"  method  of  treatment  is  being  used  with  1,800  cases,  will 
be  completed  on  December  31,  19 14,  or  8  months  from  its  in- 
auguration. It  is  probably  safe  to  estimate  that,  under  average 
conditions,  with  the  use  of  the  "Daily"  method  of  treatment, 
a  campaign  in  a  given  territory  will  require  from  8  to  1 2  months. 

10.  SANITARY  MEASURES  FOR  PREVENTION. 

The  International  Health  Commission  undertook  in  Peter's 
Hall  District,  British  Guiana,  to  locate  and  cure,  as  far  as  was 
possible,  every  person  affected  with  Ankylostomiasis,  and  to 
educate  the  people,  with  literature  and  illustrated  lectures,  in 
Modern  Sanitation  and  preventive  measures.  In  this  work  they 
were  to  have  the  support  and  co-operation  of  the  Government, 
which  would  undertake  to  inaugurate  such  sanitary  changes 
and  improvements  in  the  District  as  would  reduce  the  dangers  of 
re-infection  to  a  minimum. 

As  the  whole  question  of  the  prevention  of  the  spread  of 
Ankylostomiasis  is  simply  a  question  of  preventing  the  ova- 


20  TH^   E)RADICATI0N   OF   HOOKWORM   DIS^AS^. 

impregnated  feces  from  being  deposited  on  the  surface  of  the 
ground,  where,  in  the  presence  of  moisture  and  oxygen  the  eggs 
will  hatch  into  the  infective  embryos,  our  attention  was  natur- 
ally centered  on  the  privies  or  latrines  in  use  in  this  District. 
There  were  three  types  in  use.  Many  of  the  homes^  in  the  vil- 
lage were  found  unprovided  with  latrines  of  any  sort,  but  the 
cane  patches  and  the  "Bush"  were  used  instead  as  places  of 
concealment.  Others^  had  latrines  which  were  for  concealment 
only,  as  all  night-soil  fell  upon  the  surface  of  the  ground,  to  be 
scattered  about  by  fowls,  beating  rain,  etc. 

On  the  sugar  estates  the  latrines^  in  common  use  by  the  in- 
dentured labor  are  built  of  sheet-iron,  except  the  floors  and 
frames,  and  located  over  the  "drainage  trenches."  All  dejecta 
fall  into  the  trenches,  and  as  long  as  the  water  therein  stands  at 
its  normal  height  these  latrines  largely  prevent  Ankylostomiasis 
infection.  It  often  occurs,  however,  that  the  water  level 
recedes,  exposing  areas  of  mud-bottom  contaminated  with 
viable  Ankylostome  eggs,  and  other  pathogenic  organisms  too 
numerous  to  mention;  and  when  children  and  others  wade  into 
and  across  these  infected  spots,  they  cannot  well  avoid  contract- 
ing a  case  of  Ankylostome  "ground  itch." 

The  third  type  of  latrine  was  the  so-called  "Pit  Privy,"  in 
common  use  in  the  United  States,  and  by  far  the  most  effective 
of  the  three. 

These  privies  are  constructed  as  follows:  A  pit  of  proper 
dimensions,  and  three  to  four  feet  deep  is  dug.  Over  this  pit 
are  placed  the  seat  and  light  superstructure  so  that  all  night-soil 
falls  directly  into  the  pit.  The  earth  is  banked  up  around  the 
lower  edges  of  the  latrine  walls  to  keep  out  water.  The  seat 
should  have  a  cover  which  will  only  stay  up  when  occupied. 

When  the  pit  becomes  filled  with  night-soil  to  within  a  foot 
or  so  of  the  top,  another  pit  is  dug  near  by,  and  the  seat  and  su- 
perstructure are  moved  over  it,  the  old  pit  being  filled  up  with 
earth. 

This  latrine  is  inexpensive,  it  does  not  require  cleaning,  can 
easily  be  made  fly-proof,  and  prevents  the  spread  of  disease- 
breeding  filth.  With  its  construction  and  general  use  the 
spread  of  Ankylostomiasis  will  be  checked,  typhoid  will  become 
rare,  and  bowel-disorders  will  become  less  frequent. 

^These  homes  are  indicated  on  our  sanitary  report  sheet  as  F  types. 

^These  are  designated  as  Type  E  in  our  sanitary  sheets. 

^This  type  of  latrine  is  classified  as  D  type  on  our  weekly  report  sheets. 


PKR  CAPITA   COST. 


21. 


The  improvement  in  sanitary  condition  by  the  Government 
force  has  kept  pace  with  the  progress  of  the  curative  measures  of 
our  campaign  in  British  Guiana. 

Latrines  of  either  the  trench-  or  pit-type  have  been  put  in 
by  the  people  at  practically  every  home  in  Area  B,  and  steps  are 
being  taken  to  secure  like  results  in  the  other  Areas. 

The  existence  of  compulsory  laws  has  made  it  possible  to 
secure  very  prompt  action  in  the  District  on  Sanitary  matters. 

11.  PER  CAPITA  COST. 

In  estimating  the  per  capita  cost  of  a  campaign  for  the  com- 
plete eradication  of  Ankylostomiasis,  we  are  unfortunate  in 
not  having  a  full  report  of  a  campaign  dealing  with  a  large  area. 
From  such  a  report  definite  data  could  be  obtained.  The  cam- 
paign in  Peter's  Hall  District,  British  Guiana,  however,  does  afford 
us  complete  returns  from  a  small  area,  and  partial  returns  from  a 
larger  area,  and  it  is  possible  by  basing  our  estimates  upon  these 
to  arrive  at  results  accurate  enough  for  all  practical  purposes. 

For  our  purpose  here  we  will  take  the  "Unit  of  Area  of  Oper- 
tion,"  a  medical  district,  with  a  population  of  15,000  and  an 
infection  of  50  per  cent,  and  arrange  a  definite  budget  for  this  area. 

BUDGET. 

RUNNING   E;XPENSES. 

Medical  district,  population,  15,000;  infection  50%,  7,500  to  be  treated; 
duration  of  campaign,  four  or  six  months;  method  of  treatment, 
"Intensive." 


Force  and  salaries. 

Monthly. 

Four 
months. 

Six 
months. 

I  Supervising  medical  officer 

$150.00 
20.00 
50.00 
80.00 
25.00 
90.00 
54  00 
180.00 
60.00 
15.00 
18.00 

30.00 

$600.00 

80.00 

200 . 00 

320.00 

100.00 

360.00 

216.00 

720.00 

240.00 

60.00 

72.00 

120.00 

$900.00 

House  allowance 

120.00 

Travelling  allowance,  limited  to  . .  . 
I  Chief  clerk,  salary                    

300.00 
480.00 

I  Assistant  clerk,  salary 

I 50 . 00 

3  Microscopists,  at  $30  per  month 

3  Pioneers,  at  $18  per  month 

540.00 
324.00 

6  Nurses,  at  $30  per  month 

I ,080.00 

6  Assistant  nurses,  at  $10  per  month 

3  Caretakers  for  office,  at  $5  per  month . 
3  Offices,  at  $6  per  month 

360.00 

90.00 

108.00 

Contingent  expenses  for  three  offices,  at 
$10  per  month 

180.00 

Totals  of  running  expenses 

772.00 

3,088.00 

4,632.00 

Rate,  per  capita,    7.500   people   to   be 
treated 

$0,103 
.052 

$0,412 
.207 

$0,616 

Rate,  per  capita,    15,000  people  to  be 
examined 

•  309 

22  run   ERADICATION   OF  HOOKWORM  DISEASE- 

FIXED   EXPENSES. 

Furniture  and  utensils  for  three  offices. 

9  tables,  i8  chairs,  6  benches,  water  cooler,  towels,  etc ?  150.00 

Additional  for  central  office. 
Typewriter,  $80.00;  locked  press  for  record  books,  microscopes, 

suppHes,  etc,  $20.00 100.00 

Scientific  supplies. 
3  microscopes  at  $35.00,  Bausch  &  Lomb,  Rochester,  N.  Y. 

(special) 105  .  00 

Microscope  slides 10.00 

I  Balopticon   and   tank,  $35.00,  Bausch  &   Lomb,  Rochester, 

N.  Y 3500 

50  Bajopticon  sHdes  on  Ankylostomiasis,  P.  M.  Foltz,  Washing- 
ton, D.  C 15  00 

I  Hook  worm  chart 5  •  00 

I  Centrifuge  (special),  Bausch  &  Lomb,  Rochester,  N.  Y 15  00 

Accessories  for  same 5  •  00 

I  Kodak  or  camera 25  .  00 

Printing :  Record  books,  report  sheets,  Hterature,  etc 300 .  00 

Tin  specimen    containers,  Myers    Mfg.   Co.,   Camden,  N.  J. 

(150  gross) 75  -oo 

Thymol,  180,000  5-grain  capsules,  average  24  capsules  to  case 

treated,  $2.50  per  1,000 450.00 

Sulphate  of  magnesia 75  •  00 

Total $1,365.00 

Rate  per  capita  for  7,500  individuals  treated $0. 182 

Rate  per  capita  for  15,000  individuals  examined .091 

In  a  four  months'  campaign  Running  Expenses  give  a  per 
capita  cost  of  $.412  for  cases  treated.  Add  to  this  $.182,  the 
per  capita  cost  of  cases  treated  for  fixed  items  of  budget  showti 
above,  and  we  have  a  total  per  capita  cost  for  cases  treated 
during  a  four  months'  campaign  of  $.594.  A  six  months'  cam- 
paign would  increase  this  to  $.798. 

12.  IS  COMPLETE  ERADICATION  POSSIBLE? 

There  is  probably  no  disease,  certainly  no  other  parasitic 
disease,  of  which  our  knowledge  is  so  complete  as  it  is  of  Anky- 
lostomiasis, and  for  which  we  have  two  or  more  specific  drugs. 
There  is  not  a  missing  link  in  our  knowledge  of  the  Ankylostome, 
from  the  moment  the  ^gg  reaches  the  soil  in  the  feces  of  its  host 
and  hatches  into  the  embryo ;  throughout  all  the  stages  of  devel- 
opment until,  in  its  "encysted"  stage,  it  enters  the  human  body, 
to  reach  finally  the  small  intestine,  there  to  live  for  eight  or  ten 
years,  reproducing  its  kind  in  countless  thousands.  Every  detail 
of  its  life-history  and  the  necessary  environments  for  its  develop- 


IS   COMPI^E^T^   ERADICATION   POSSIBLE)?  23 

ment  are  points  rendered  very  familiar  by  the  researches  of 
the  scientists.  ^ 

With  such  perfect  knowledge,  then,  it  has  been  an  easy  task 
to  elaborate  a  perfect  theory  for  the  prevention  of  the  disease. 
Only  one  thing  is  necessary;  that  is,  to  prevent  soil-pollution, 
in  other  words,  to  keep  the  Ankylostome  ova  from  reaching  the 
soil  where  it  could  hatch  and  develop  into  the  infective  embryo. 

If  those  who  have  the  disease  can  be  cured,  and  we  know  how 
to  prevent  others  from  contracting  it,  then  complete  eradication 
is  at  least  theoretically  possible. 

Let  us  consider  briefly  what  are  the  necessary  steps  to  accom- 
plish complete  eradication. 

1.  The  microscopic  examination  of  every  individual  in  the 
field  of  operation. 

2.  The  treatment  of  every  infected  individual  until  cured. 

3.  The  installation  and  use  of  proper  closets  or  latrines, 
preventing  further  "soil-pollution." 

4.  The  protection  of  the  people  against  infection  by  Anky- 
lostome embryos  already  in  the  soil. 

Although  the  problem  of  complete  eradication  seems  simple, 
when  thus  put  upon  paper,  it  is  not  found  so  when  actually 
attempted,  for  many  difficulties  develop.  Every  difficulty, 
however,  can  be  rightly  attributed  to  one  cause,  "lack  of  ade- 
quate co-operation  on  the  part  of  the  people."  This  lack  of 
co-operation  was  evident  from  the  first  day  of  our  campaign 
until  its  close,  and  since  human  nature  is  much  the  same  the 
world  over,  this  will  probably  be  true  in  some  measure,  no  matter 
where  the  campaign  be  waged. 

Taking  up  the  four  essential  steps  to  complete  eradication, 
let  us  briefly  note  some  of  the  difficulties  which  make  against 
complete  success: 

I.  The  microscopic  examination  of  every  individual  in  a 
given  area  of  any  extent  has  never  been  possible,  in  the  experi- 
ence of  the  writer.  There  have  always  been  those — few  though 
they  may  be — who  refuse  to  submit  specimens  for  examination. 
Widely  varying  reasons  are  advanced  by  these  people  for  their 
failure  to  co-operate,  and  it  may  be  of  interest  to  mention  those 
most  frequently  met  with  in  Peter's  Hall  District. 

(a)  A  false  sense  of  modesty  prevented  some  from  preparing 
and  submitting  specimens. 

(b)  People  of  apparent  good  health,  though  they  might  have 
mild  infections,  did  not  feel  the  need  of  examination  and  treat- 
ment. 


24  THE   ERADICATION   OF  HOOKWORM   DISEASE. 

(c)  Among  the  illiterate  class  unreasonable  suspicion  and  su- 
perstition deterred  some.  ^ 

(d)  Others  because  of  social  prominence,  intellectual  attain- 
ments, or  wealth,  seemed  to  consider  themselves  immune  to 
the  disease. 

{e)  There  were  some  who  were  openly  hostile,  seeming  to  see 
in  the  campaign  an  attempt  to  interfere  with  their  personal 
liberties. 

(/)  The  indifferent  and  negligent  class  furnished  its  usual 
quota  of  incorrigibles. 

The  following  extracts  from  the  reports  of  Peter's  Hall  Dis- 
trict for  August  15,  1 9 14,  show  the  number  refusing  examination : 

Population  of  Area  B,  Peter's  Hall  District,  as  shown  by  actual 

census  taken  by  staff  of  International  Health  Commission.  .  .  .    3,563 
Number  examined  for  Ankylostomes  by  the  staff  of  the   Inter- 
national Health  Commission  in  Area  B 3,207 

Number  refusing  examination,  some  removing  from  area,  and  others 

remaining  as  possible  foci  of  infection  (10%  of  the  population) .  .        356 
In  Meadow  Bank  village,  Area  A,  population  as  shown  by  census.  .       520 

Examined 467 

Number  refusing  examination  or  removing  from  village  (approxi- 
mately 10%) 53 

2.  The  treatment  of  every  individual  affected  with  Ankylos- 
tomiasis, until  cured,  depends  upon  the  willingness  of  the 
patients  to  take  the  treatment  for  a  sufficient  length  of  time. 
Here,  as  in  the  question  of  microscopic  examination,  there  are  a 
small  number  who  persist  in  refusing  treatment,  even  though 
shown  that  they  harbor  the  parasite. 

There  are  others  who  abandon  the  treatment  short  of  a  com- 
plete cure,  and  a  small  number  who  are  refused  treatment  for 
medical  reasons,  thymol  being  contra-indicated  because  of 
intercurrent  diseases. 

The  number  that  refuse  or  abandon  treatment  is  usually 
smaller  than  the  number  refusing  examination,  as  is  shown  by  the 
following  figures  taken  from  the  reports  from  British  Guiana : 

Agricola,  Peter's  Hall  District} 

Positive  cases  reported  July  20 619 

Number  starting  treatment 619 

Number  cured 311 

Number  under  treatment 239 

Number  abandoning  treatment  (11%) 69 

Number  refusing  treatment  (not  reported) 

Meadow  Bank,  Area  A,  Peter's  Hall  District. 

Number  positive  cases  reported 275 

Number  starting  treatment 211 

Number  reported  cured '  •  •  •  : 209 

Number  abandoning  treatmentl  ^  .  0/  / 2 

Number  refusing  treatment       J  "^"^  ^^  \ 7 


Campaign  not  yet  completed. 


IS  COMPLETE   ERADICATION   POSSIBLE?  25 

The  difference  between  the  number  found  positive  and  the 
number  treated  and  cured  will  vary  in  proportion  as  the  Super- 
vising Medical  Officer  is  patient,  persistent,  and  tactful,  or  other- 
wise. 

3.  The  installation  of  sanitary  closets  or  latrines  is  possible, 
as  has  been  demonstrated  in  parts  of  Peter's  Hall  District  and 
elsewhere.  Compulsory  laws  with  penalties,  if  enforced,  will 
secure  results,  but  better,  and  much  more  to  be  desired,  are  the 
results  obtained  by  a  campaign  of  education  and  enlighten- 
ment, which  creates  a  public  demand  for  such  improvements. 
After  such  closets  are  installed,  we  still  face  the  difficulty  of 
securing  their  use  by  the  people.  This  is  not  in  my  opinion, 
however,  the  hopeless  task  that  some  have  expressed  it  to  be. 
In  Peter's  Hall  District,  with  its  mixed  population,  consisting 
largely  of  ignorant  Blacks  and  East  Indians,  the  patient, 
tactful,  and  yet  firm  handling  of  this  question  brought  really 
lemarkable  results. 

4.  Efforts  to  protect  the  people  from  infection  from  the 
already  existing  Ankylostomes  in  the  soil  are  possibly  less 
promising  of  success  than  any  other  feature  of  eradication. 

Because  of  the  labor  involved  it  is  often  impracticable  to 
attempt  to  locate  areas  where  the  soil  is  infected  with  the 
Ankylostome  ova  and  embryos.  If  such  areas  were  located 
they  would  probably  be  too  extensive  to  make  their  destruction 
possible,  or  to  keep  the  people  away  from  these  infective  points. 

Attempts  at  the  destruction  of  the  Ankylostome  ova  and  em- 
bryos in  the  soil  by  the  use  of  chemicals  have  not  been  entirely 
satisfactory.  In  a  paper  read  before  the  Society  of  Tropical 
Medicine  and  Hygiene,  by  Sir  Thomas  Olliver,  in  19 10,  the  state- 
ment is  made  that  "The  one  salt  which  has  given  the  most 
satisfactory  results  all  around  is  Iron  Sulphate.  It  is  estimated 
that  one  ton  of  this  in  a  i  per  cent  solution  would  cover  a  length 
of  60  miles,  more  than  a  yard  wide,  and  one-third  of  an  inch 
deep."  This  solution  was  used  to  a  limited  extent  in  Peter's 
Hall  District,  and  brush  and  trash  piles  were  burned  on  spots 
likely  to  be  heavily  infected,  such  as  sites  of  surface  closets, 
stooling-places  in  thickets,  and  in  cane-fields,  etc. 

It  is  possible  to  meet  the  difficulties  presented  by  this  fourth 
and  last  essential  to  complete  eradication  by  keeping  the  entire 
population  under  observation  until  sufficient  time  has  elapsed 
for  all  Ankylostome  embryos  in  the  soil  to  die,  probably  about 
ten  months;  or  to  arrange  a  return  campaign,  when  cases 
resulting  from  re-infection  from  this  source  may  be  found  and 
cured. 

Summing  up  the  situation,  we  may  say  that  while  the  com- 
plete eradication  of  Ankylostomiasis  in  a  given  territory  is  theo- 
retically possible,  practically  it  can  only  be  approximated. 


26  THE   ERADICATION   OF  HOOKWORM   DISEASE. 

What,  then,  are  the  results  and  benefits  of  a  properly  con- 
ducted campaign  of  this  nature? 

1.  Approximate  eradication  is  obtainable.  How  nearly  eradi- 
cation was  approximated  in  British  Guiana  is  indicated  by  com- 
plete returns  from  one  village  and  partial  returns  from  another. 

Report  from  Meadow  Bank  village,  Peter's  Hall  District, 
August  15,  1914: 

"  Of  the  233  positive  cases  remaining  in  Meadow  Bank  village 
at  the  close  of  the  two  months'  campaign,  209  were  cured.  The 
24  not  treated  are  reported  as  follows : 

7  refusing  treatment.        2  abandoning  treatment. 

15  were  refused  treatment  because  of  pregnancy,  or  inter- 
current diseases  contra-indicating  the  use  of  thymol. 

Percentage  cured,  90." 

In  Agricola  village  the  campaign  is  not  yet  completed,  but 
of  the  619  cases  beginning  treatment,  311  are  reported  cured, 
and  239  are  continuing  treatment  with  prospect  of  early  cures 
in  practically  all  of  this  number. 

We  see  from  these  reports  that  these  campaigns  mean  the 
cure  of  a  large  percentage  of  those  affected  with  Ankylostomiasis. 
In  Peter's  Hall  District  it  means  the  restoration  to  health  and 
happiness  of  hundreds  of  severe  cases,  of  all  ages,  and  degrees 
of  infection  ranging  from  physical  unfitness  to  labor  and  con- 
sequent poverty  and  want,  to  advanced  bed-ridden  invalidism. 
Scores  of  children,  whose  mental  and  physical  development  were 
endangered,  will  be  free  from  the  disease  and  restored  to  their 
natural  heritage  of  buoyant  health  and  vitality.  It  means  the 
relieving  of  the  mothers  of  the  District  from  the  dangers  of  a 
disease  which  during  pregnancy  and  at  childbirth  has  enor- 
mously increased  the  maternal  death-rate. 

2.  As  a  result  of  our  campaign  the  increased  activity  of  the 
sanitary  authorities,  together  with  the  awakened  interest 
of  the  people  in  improving  sanitary  conditions,  have  brought 
results  which  will  lead  to  a  marked  decrease  in  Typhoid,  Dysen- 
tery, Diarrhoea,  and  kindred  troubles. 

3.  The  campaign  was,  in  this  instance,  as  it  generally  is,  a 
"pioneer  movement,"  and  "blazed  out"  and  made  easy  the  way 
for  other  crusades  against  preventable  diseases  which  the  future 
necessarily  will  bring. 

4.  If  the  following  efforts  be  steadily  continued — 

(a)  To  improve  sanitation  and  stop  soil-pollution ; 

(b)  To  educate  the  people  concerning  the  cause  and  preven- 
tion of  the  disease; 

(c)  To  provide,  after  the  close  of  the  campaign,  for  the  free 
treatment  of  all  cases  of  Ankylostomiasis, 

then  it  would  seem  reasonable  to  hope  for  eventual  eradication, 
an  end  probably  not  attainable  save  by  aiming  at  and  striving  for 
complete  eradication  during  the  initial  campaign  in  any  given 
community. 


APPENDIX 


Forms  and  Financial  Regulations 


27 


APPENDIX. 
WEEKLY  REPORT.  District, 

CENSUS,    SANITARY    SURVEY,    EDUCATIONAL. 
_ ^Dispensary   for    Week    Ending 


.19. 


Location. 

H.No. 

Individuals. 

Latr.nks.     Class.        | 

KE.\IAKKS. 

D 

E 

F 

ToUl. 

(Size  of  form  12|*  x  8")         . 

Totals 

EDUCATIONAL 

LITERATURE 

DISTRIBUTED 

DATE. 

LKCrUREB. 

Bv  Whom 

^-"y-        Atl°nd. 

Date. 

Locality 

Circulars. 

Sheets 

D.7 

Night. 

Signed 


29 


30 


TH^   ERADICATION   OF  HOOKWORM   DISEASE. 


z 

o 

s 


C 
(D 

a 

CO 


o 

S 
o 


o 
o 

X 


S 

2 


< 

UJ 

z 

u: 

UJ 

d 

i 

< 

o 

z 

UJ 

O 

I 

UJ 

u 

< 
a: 

^ 

z 

i 
: 

Mao 

o  -d   o  fl  <D 

O          ^  .H  > 

,Q    05  o 

<D    <D    $^  O  Od 

to  ,Q    O  iH 

0)  .H  <D 

,q   o  «H  «H  a> 

Eh  4^  o  (Q 

oj  — . 


^   fi 


08    ^ 


rt  ©  +»  ,i^  -P 

■P  p  ^^  rt 

«H  O  rH 

5   iH    O  ^ 

00  .H  -CO  m  o 

o  ^  e  (S  o 

©    .H     ©  43 

4:»    ^  O  O 

.        e  (8  -H 

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.Q    ©    O  .rt 

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to    ti   .H 

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o  o 

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CO    P4 


CO  rt  o  rt  = 

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rt   o  t:} 

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rt  .  rt  lO 

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rt  6  +>  ■«  . 

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o  o  03  rrt  o 

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r-^  rt  o  *H 

©     O  ©  03  © 

•H    +9  O  «H 

<H  •  © 

Tj  ©  >>  Jh 

>H   ©  .rt  rt 

^   S  ti  ;rt  «H 

6    >H  O  O 

K   >H  <H  rt  © 

p    flj  ©  o 

P^  ^  .H 

— '    ©  tH  ^4  «H 

>H  O  O  Vl 

rt  ^  vt  o 


rt 
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^ 


•rH  Eh  rH  -d 

rt  o    © 

u  ft-d 

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03  r-l     >• 
©©•HO 

43     rt  O     ^H 

+S    -H  03     Pi 

>^  _ 

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^»    rH  +>     rt 

•  P  .H     03 
W  *H     60 

.    03  +>    rt 

n    rt  C3    'H 


APPENDIX. 


31 


District, 
REPORT    OF    MICROSCOPISTS. 


Arcft.. 




-  -.  _ Dispensary   for   Week   Ending. 



Wl 

Locality. 

No. 
Fjumlned 

A.D. 

A.L. 

T.D 

Kh.  I. 

O.Vli 

T.8. 

T.N. 

Tueaday. 

Totals      

Wedaesday. 

Totals     

(Each  sheet  of  this  form  provides  for  the  recording  of  the  microsoopioal 
work  done  at  6  different  points  in  a  district  and  on  the  6  days  of  the  weel< 
All  of  this  work  is  supposed  to  be  done  at  the  central  office  dispensary.) 


(Size  of  form  6"  x  13") 

1 

Tboraday. 

Totals 



Pridttv. 

Totals     

Totals      

Totals      

Signed 


101 


32 


THE  ERADICATION  OF  HOOKWORM  DISEASE. 


INFECTION     SURVEY. 

DISPENSARY  FOR  FREE  TREATMENT  OF  ANKYLOSTOMIASIS. 


Report  of Supervising  Medical  Officer,   Week  ending 

Area .District Dispensary  a... 

MICROSCOPICAL  EXAMINATIONS  AND  RESULTS. 


Daw. 

Location. 

-^^ 

A.L. 

T.D. 

Rh.  I. 

o.v.  1 

T.S. 

VS. 

+ 

_ 

+ 

+ 

+ 

-f- 

+ 

-h 

. 

1                  1                  1                   f                   1                   1 

(Weakly 

report,  sheet  for  use  of  superyising  medical  of 
(Size  of  form  12^  x  8") 

floer) 

TOIAM 

No.  in  Censui 

- 

Signed 

No.  Examined 

No   Poa  Al) 

.^ _ 

No.  NeR.  A.D 

' 

APPENDIX. 


33 


-Eh 

Qj    -  o  OS  q 

f^  ti  -M  h  o 

^    Vh     >i   (U    ?1     (H  rt 


8 s|^-§ si--s.gr  5 


D 


u^  i-a  8^  2 


^  ..  c  ^  S 


V^  d  v^  ^  o -a^  fi  g  ^  o 

OJ^  Q  0(4-'  cu-M.t:^   '^^-Vh 
^  ^  ^  t«   c3  cj   rt   6   ^   2  I 


oj  rt  y  ^ /d  -;:? 

w  i-i  p 

c!  S    O 

«  oj  p 


M  2 


Oj 

"1- 


CO     Q 

OJ  O     . 


«•§ 


ci  ^  ji  t/,  w  -5  ii  •'3  o  .t;  "^ 


>  ii  dj  s  o  '^ 
?  (N  a;  g  o  +-> 

)_,+j_jC/j(yajc3,H 

M 
c3 


2^  ^ 


-g  o  ^ 


c« 


:5-s 


::::  iJ  oj  o 

'^  ?.  i!  15  o 

5  5'0  -M'd 
:3  rt  C  "5  <u 
o  S  o  O.N 


C/3  O       .«  i-(   O 


r1  t:  "^  >>  oj  '^  i; 

U    a    J-]  '-I    rj    <u  hi 

<U    Tv  -^  ij  j2  3  , 

^    >    OJ    CO  /"  _ 


34 


ERADICATION   OF  HOOKWORM  DISEASE- 


Report  of_ 
Area 


MSPEHSART  TOR  niEE  TREATMENT  OF  AHKTLOSTOMIASIS. 
.     S,  M.  0.  Week  ending 


1914. 


Dlttrict 


Dlspen8ea*7  at^ 


Treatments      . 

ANKYLOSTOMIASIS 

Location 

Se^ 

a 

1 

1 

i 

3 

5 

'6 

Totals             tate      Sumnary           Totals  to  date] 

Census 'Return 

Positive  to  AD 

■ 

Cured 

Abandoned 

Removed 

Refused 

Died 

To  be  treated 

' 

Totals 

Treatment 8<   - 

Location 

i«^"  .^_:  ._  ■;■ ^ 

2, 

2 

^r 

4 

5 

6 

Totals             Date           Remarks                                   1 

LLOWm  TREATMENT, 

ftHKTLOSTOMIASIS 

Tfdatmints.  Ho.    eiven   before  re-examination     . 

2nd          1 

3rd 

4th 

5th 

6th 

Pos. 

NOK. 

POB. 

Ne^. 

Pos. 

Nep;. 

Pos. 

Ne^. 

Pos. 

NSR. 

Uzarle 

1 

8nd          1 

3rd 

4 

th 

5th 

6th 

Pos. 

INeE. 

POB. 

Nep;. 

Pos. 

Nor. 

Pos, 

Nepi, 

Pos, 

Nor. 

[.umbriooldes. 

J 

L 

L 

=J 

Remarks:- 


(Size  of  form  9-3/4"  x  7-3/4") 


APPENDIX. 


35 


StMilARY  OF  1P0RK  ACCX)liFLISHID  HJ  — 

"Previous  Reports"  cover  a  period  from  

•^Present  Reports"  cover  a  period  from 


I.  ZXAUIHATIONS. 


No. in  Previous  Reports 


No.  in  Present  Reports 


TfttalB  to  date 


Census 


No.  Examined 


No.  Infected 


II.  TREATUENTS. 


I.  in  Previous  Reports 


Ko.  in  Presant  Reports 


Totals  to  date 


Treated 


No.  Cured 


No.  Under  Treatment 


III. 

SANITARY  SURVEY - 

Latrine  Types  on  1st  Inspection  | 

Types  chanzed  on  last  inspection        I 

A 

B 

C 

D 

E 

F 

Total 

F 

to 

A 

F 

to 

B 

F 

to 

C 

F 

to 

D 

F 

to 

E 

E 
to 

B 

E 

to 

C 

E 

to 

D 

D 

to 

A 

D 

to 
B 

D 

to 

C 

c 

to 
A 

C 

to 
B 

B 
to 

A 

SANITARY  INDEX.                                                    1 

Date 

First  Inspection 

Date 

Last  Inspection 

IV.  EXPENDITURES. 


Local  Funds 

Grovernment  Funds 

-Y:  A'.-t.   funds 

Amt.  in  Previous  Reports 

Anit.  in  Present  Report 

Total. 

. 

.._ 

V.  BLOOD  EXAMINATIONS.   HEMOGLOBIN  PER  CENT. 


No. nearest  to: 

0^ 

10^ 

■30f- 

'5d^- 

m'" 

'Sof 

10056 

Toial  ■■  ■ 

Previous  report 

PrARfin+.  rnpnrt 

JLDlBla 

_- 

— 1 

■: 

VI.  EDUCATIONAL. 


LECTURES  AND-  ATTENDANCE 


Previous  report 

Present  report 

1 IslaL 

To  Schools  Attendance 

Attendance 

Special 

(For  use  in  making  summaries  for  any  period;  al-so  for  making  quarterly  reports] 
(Size  of  form  9-3/4"  x  7-3/4) 


36  KRADICATION   OF  HOOKWORM  DISEASE. 


Free  Treatment    For  Ankylostomiasis 

(HOOK  WORM  DISEASE) 

1  Oil  «liiy  prooeding:  tlio  f  reatjupnt  lake  a  lar^e  dose  of  Epsom  SaltR  at  5  P.M    This 

should  opeii  thf"  bowt-ls  sevec.*!  i'unes  thorotighly.     Retire  without  food. 

2  Keinain  in  bed  the  following  morninor.     Take  no  food. 

3  At  6  A.M.  take capsules.     At  8  AM.  take capsules. 

4  At  11  A.M.  take  a  larg**  dose  of  Fp.<iorfts  Salts.     This  should  open  the  l.owels 

8  or  4  times  within  2  hours.     If  not,  repeat  the  dose.     Remain  in  the  b»^<J 

until  the  Salts  has  acted  well. 
r.  'So  food  should  ho  t;iken  until    sifter  the  Salts  ha*?  acted  thoroughly.    Then 

oul)  tnke  coffee  or  ttm  without  milk,— crackers  without  buUer,  and  fruit, 
fi  No'greasy  or  oily  food  must  be  taken, —no  uiilk,  wine,  beer,  nor , an j  alcoholic 

drinks  must  be  taken  during  the  day  of  the  treatment. 

7  The  uruhI  diet  and  habits  may  be  resumed  on  the  day  following  treatment. 

8  If  patient  feels  weak  or  dizzy  during  treatment  give  a  half  cup  of  black  coffee 

without  milk  or  sugar, 

9  Have  patient  save  all  bowel  movements  from  the  second  dose  of  Salts,  and 

examine  and  count  the  worms  expelled. 

10  In  cases  where  Epsoms  Salts  is  not  well  retained,  give  it  in  hot  water,  or 

report  to  the  Chief  Inspector. 

11  .Several  treatments  given  in  this  way  at  intervals  of  a  week  are  usually  necer 

sary  for  a  cure. 

(Size  Of  original  4*»  x  5**) 


DISTRIBUTION  BOOK  FOR  NURSES. 

The  Distribution  Book  for  the  use  of  nurses  in  giving  thymol 
is  a  reproduction  of  the  first  page  of  the  case  record  book  (see 
form  on  page  33)  except  that  it  provides  for  4  weeks  and  under 
each  week  there  are  6  treatment  columns.  These  books  should 
be  paged  to  accommodate  about  350  names  as  a  nurse  can 
usually  handle  50  cases  daily,  so  that  this  number  provides  him 
with  sufficient  cases  for  the  7  days  of  the  week. 


The  card  or  certificate  form  shown  below  was  issued  to  those 
not  found  infected,  and  also  to  those  treated  and  cured.  The 
word  "with"  is  to  be  written  into  the  blank  preceding  the  word 
"treatment"  where  the  patient  has  been  cured,  and  the  word 
"without"  where  the  first  examination  showed  no  infection. 


DISPENSARY  FOR  FREE  TREATMENT  OF 
ANKYLOSTOMIASIS. 

CBRTlIflCATE     OF    H^AIvTH. 

This  certifies  that 

of village.  Case  No 

House  No has  been  examined  and  found  free  from 

Hook  Worm  disease, treatment. 

Signed, , 

S.  M.  O. 
Date 

Medical  District 


SUGGESTED  OUTFIT  FOR  MICROSCOPISTS. 

The  following  is  a  suggested  outfit  for  use  in  field  work  which 
can  be  obtained  from  the  Bausch  &  Lomb  Optical  Company, 
Rochester,  New  York,  U.  S.  A.,  and  probably  also  from  other 
companies.  The  approximate  cost  of  this  outfit  is  $20.  A 
larger  list  of  accessories  will  be  necessary  where  more  than  one 
microscopist  is  to  make  examinations. 

1.  Special  centrifuge  with  Stewart  Pan- Head  for  20  tubes. 

2.  100  glass  tubes  open  at  both  ends,  75  x  9  mm. 

3.  100  small  funnels  for  filling  tubes. 

4.  1,000  corks,  XX,  Short,  No.  o. 

37 


SET  OF  BALOPTICON  SLIDES  SELECTED 
BY  THE  AUTHOR. 


Maker's 
No. 

308. 

I. 

202. 

2. 

39. 

1528. 

3- 
4- 

1527- 
1526. 

5- 
6. 

743- 

7- 

307- 

8. 

91. 
296. 

9- 
10. 

1081. 

II. 

1395- 

12. 

1309. 
1306. 

13- 
14. 

1307. 

15- 

I3II- 

16. 

72. 
66. 

17- 
18. 

118. 

19- 

299. 

20. 

2613. 

21. 

1540. 

22. 

359. 

23- 

1317- 

24. 

1259- 

25- 

1320. 

26. 

2317- 
2396. 

27. 
28. 

1501. 

358. 

2486. 

29. 
30. 

31- 

2617. 
2619. 
2617. 

32. 
33- 
34- 

2624. 
2611. 

35- 
36. 

Suggested  order  for  display  and  description  of  slides. 
Eggs  of  hookworm,  diagrammatic. 
Eggs  of  hookworm,  under  microscope. 
Larvae  of  hookworm,  two  stages  of  development. 
Ground  itch,  on  toes,  instep  and  ankle. 
Ground  itch,  on  bottom  of  foot. 
Ground  itch,  between  toes. 

Ground  itch,  "bunches"  on  arm  of  Cornish  miner. 
Section  of  skin  showing  larvae. 
Section  of  lung  showing  larvae. 
Hookworm  after  reaching  intestines. 
Hookworm,  adult,  scale  showing  size. 
Experimental  hookworm  infection. 
Experimental  hookworm  infection. 
Experimental  hookworm  infection. 
Experimental  hookworm  infection. 
16.  Experimental  hookworm  infection. 
Hookworm  mouth,  front  view. 
Hookworm  mouth,  side  view. 
Hookworm  attached  to  mucosa. 
Wounded  area  of  intestine. 
Lettered  slide.     "Symptoms." 
Two  girls  with  hookworm  disease. 
Entire  family  with  hookworm  disease. 
Boy  with  disease,  average  severity. 
Boy  with  disease,  severe  type. 
Girl  with  disease,  average  severity. 
Girl  with  disease,  severe  type. 
Negro  boys,  brothers. 
29.  Two  boys,  same  age  (18  yrs.). 
Boy,  21  years  old,  dwarfed. 
Map,  tropical  world. 

"Beni,"  first  patient  treated  on  foreign  soil. 
Child,  5  months  old  with  the  disease. 
East  Indian  woman,  90  years  old. 
East  Indian  girl,  severe  case. 
Vicious  circle  of  hookworm  disease. 
(A  further  list  of  slides  may  be  obtained  from  Pierre  M.  Foltz,  302  E 
St.  N.  E.,  Washington,  D.  C.) 


38 


APPENDIX.  39 

R^Gui^ATioNS  Governing  Accounting  Procedures  in  Con- 
nection WITH  Offices  of  Directors  in  the  Field. 

1.  Home  office  and  field  office  funds. — Bills  due  in  the  United 
States  are  to  be  paid  from  funds  deposited  with  a  bank  located 
in  Washington,  D.  C.  and  designated  by  the  Commission. 
Such  funds  shall  be  known  in  the  bookkeeping  of  the  Commis- 
sion as  '/Home  Office  Funds." 

Bills  due  in  the  country  in  which  the  office  of  a  director  is 
located  or  in  other  countries  outside  of  the  United  States  shall 
be  paid  out  of  funds  deposited  at  the  place  where  the  headquar- 
ters of  the  director  is  located.  Such  funds  shall  be  known  in 
the  bookkeeping  of  the  Commission  as  "Field  Office  Funds." 

2.  Preparation  of  vouchers.— M\.  vouchers  shall  be  prepared  in 
triplicate  by  use  of  forms  to  be  provided  by  the  Commission. 
The  three  copies  will  be  distinguished  by  colors  as  follows: 
original,  white;  duplicate,  pink;  triplicate,  primrose. 

In  making 'payments  out  of  field  office  funds  the  word  "home," 
and  in  making  payments  out  of  home  office  funds  the  word 
"field"  should  be  crossed  out  on  the  voucher.  The  name  of 
the  budget  should  be  indicated,  together  with  the  budget 
number.  The  first  budget  adopted  for  a  given  area  or  country 
will  be  budget  No.  i.  The  second,  No.  2,  etc.  A  voucher 
charged  against  field  office  funds  under  budget  No .  2  of  Panama 
would,  e.  g.y  bear  the  words,  "Panama  No.  2"  in  the  space 
provided  on  the  voucher.  Vouchers  should  be  made  out  in  the 
currency  of  the  country  in  which  payment  is  made.  Where 
two  standards  of  currency  are  in  use  the  one  adopted  by  the 
government  should  be  accepted  by  the  Commission  rather  than 
the  one  in  use  by  banks  and  commercial  houses. 

Vouchers  used  in  countries  in  which  the  English  language  is 
not  used  should  bear  on  their  face  a  translation  of  the  various 
items  stated  in  the  foreign  language.  In  making  out  a  voucher 
the  address  as  well  as  the  name  of  the  individual  or  firm  should 
be  indicated. 

Bach  set  of  vouchers  should  be  serially  numbered  in  an  inde- 
pendent series.  Where  a  voucher  is  drawn  against  "Home 
office  funds"  its  number  should  agree  with  the  number  of  the 
check  by  which  the  voucher  is  paid.     Each  voucher  should  also 


40  THE   ERADICATION  OF  HOOKWORM  DISEASE. 

plainly  indicate  by  item  number  the  budget  item  against  which 
it  is  to  be  charged. 

3.  Description  of  equipment  in  vouchers. — The  Commission 
keeps  an  accurate  record  of  all  equipment  and  other  property 
purchased  in  the  field.  It  is  important  in  drawing  vouchers 
to  describe  carefully  all  such  property  by  manufacturer's  num- 
ber, size,  type,  or  other  definite  identification. 

Outlays  for  property  which  are  not  budgeted  as  such  but 
which  are  paid  for  out  of  the  contingent  fund  should  be  described 
as  such  on  the  voucher  by  writing  "outlay"  after  the  item. 

4.  Use  and  disposition  of  copies  of  vouchers. — 

{a)    IN  MAKING  PAYMENTS  OUT  OF  "FIELD  OFFICE  FUNDS." 

1.  The  original  and  duplicate  copies  of  the  voucher,  together 
with  the  supporting  bill,  will  be  sent  to  the  proper  party  for 
receipt. 

2.  The  triplicate  copy  will  be  kept  on  file  to  check  up  the  re- 
turn of  the  original  and  duplicate  copies  and  to  protect  the 
field  office  in  case  of  loss  in  the  mail. 

3.  On  return  of  the  original  and  duplicate  copies,  together 
with  bill  properly  receipted,  the  original  and  the  bill  (both 
receipted)  will  be  kept  in  the  files  of  the  field  office  until  the 
close  of  the  quarter  when  they  will  be  sent  to  the  Commission 
at  Washington,  D.  C.  The  duplicate  and  triplicate  copies  will 
be  filed  in  the  field  office,  the  duplicate  in  a  permanent  file,  and 
the  triplicate  in  a  temporary  file  for  use  in  bookkeeping  and  for 
destruction  after  a  period  of  one  year,  if  no  other  use  is  found 
for  it. 

(^>)    IN  MAKING  PAYMENTS  OUT  OF   "  HOME   OFFICE  FUNDS." 

1 .  The  original  and  duplicate  copies  of  the  voucher,  together 
with  the  supporting  bill  and  check  drawn  by  the  field  office 
on  the  Washington  bank  of  deposit,  will  be  forwarded  to  the 
Commission  at  Washington.  The  Commission  will  in  turn  for- 
ward the  papers  to  the  proper  person  for  receipt.  On  return  to 
the  Commission  of  the  papers  described  the  original  copy  of  the 
voucher  and  the  bill  will  be  retained  in  the  files  of  the  Com- 
mission. The  duplicate  copy  of  the  voucher  will  be  returned  to 
the  Director  in  the  field  from  whose  office  it  emanated. 

2.  The  triplicate  copy  of  the  voucher  will  be  retained  in  the 
office  of  the  Director  in  the  field  to  check  up  the  return  of  the 


APPENDIX.  41 

receipted  duplicate  from  the  Commission  at  Washington. 
On  receipt  of  the  dupHcate  from  the  Commission  the  use  and 
procedure  will  be  the  same  as  in  case  of  duplicate  receipted 
vouchers  received  for  payment  of  bills  from  "Field  Office 
Funds." 

5.  Supply  of  funds  J  or  field  office  and  home  office  account. — The 
Commission  will  be  notified  one  month  prior  to  the  close  of 
each  quarter,  or  earlier  if  practicable,  as  to  the  estimated 
amount  of  all  bills  which  are  to  be  paid  for  out  of  "  Home  Office 
Funds"  during  the  next  ensuing  quarter.  The  Commission  will 
then  draw  one  voucher  to  cover  the  amount  of  the  budget  which 
is  to  be  used  in  the  payment  of  bills  from  the  "Field  Office 
Funds,"  and  a  second  voucher  to  cover  the  amount  of  the  bud- 
get which  is  to  be  used  in  the  payment  of  bills  from  the  "  Home 
Office  Funds."  The  check  received  from  the  Foundation  head- 
quarters in  New  York  to  supply  "Home  Office  Funds"  will  be 
deposited  with  the  Washington  bank  of  deposit.  Duplicate 
deposit  slips  properly  certified  will  be  forwarded  to  the  Director 
in  the  field  for  his  information. 

Every  effort  should  be  made  to  estimate  carefully  the  amount 
of  money  which  will  be  required  to  pay  bills  incurred  in  the 
United  States  within  a  given  quarter.  Should,  at  any  time, 
the  total  payments  exceed  the  amount  available  in  the  "Home 
Office  Funds"  of  the  field  office  concerned,  the  International 
Health  Commission  will  temporarily  advance  the  money  needed 
to  meet  the  unexpected  demands  upon  such  funds.  Any  excess 
amounts  thus  paid  for  field  offices  will  be  adjusted  at  the  time 
of  the  remittance  for  the  next  ensuing  quarter.  In  case  of  the 
completion  of  a  campaign  within  a  particular  quarter  in  which 
excess  payments  were  made  by  the  International  Health 
Commission,  the  field  office  will  remit  to  the  International 
Health  Commission  the  amount  due,  together  with  such  other 
unexpended  balance  as  may  remain  in  the  hands  of  the  field 
office,  at  the  time  of  the  close  of  the  campaign. 

Remittances  made  to  field  offices  will,  wherever  expedient, 
be  made  through  the  office  of  the  Director  in  Charge.  In 
other  cases  a  statement  showing  the  details  of  the  remittances 
will  be  sent  to  the  Director  in  Charge  and  the  voucher  and 
check  sent  directly  to  the  foreign  government  or  to  the  local 
subordinate  in  charge  in  a  particular  country. 


42  TH^  ERADICATION   OF  HOOKWORM  DISEASE. 

No  checks  will  be  drawn  against  vouchers  until  they  have 
been  properly  approved  by  the  director  responsible  for  the  fund 
out  of  which  paid  and  by  the  proper  authority  of  the  foreign 
government  wherever  such  approval  is  required. 

6.  Deposit  of  field  office  funds. — Whenever  money  is  deposited 
for  field  office  funds  such  deposits  will  be  made  to  the  credit  of  the 
International  Health  Commission.  Payments  from  the  fund  will 
be  made  in  the  name  of  the  International  Health  Commission, 
and  the  receipt  taken,  as  indicated  by  the  voucher  form,  will  like- 
wise be  in  the  name  of  the  International  Health  Commission. 

7.  Contingent  funds  for  field  use. — In  order  that  the  contingent 
fund  for  field  use  may  be  kept  at  a  minimum,  every  effort  should 
be  made  to  budget  expenses.  A  contingent  fund  ledger  record 
will  be  kept  in  each  office  of  a  Director  in  the  field.  This  record 
will  be  supplemented  by  a  petty  cash  record  showing,  by  voucher 
numbers,  the  amounts  withdrawn  for  petty  cash  purposes  as 
well  as  the  item  to  be  credited  to  the  petty  cash  account. 

Vouchers  drawn  against  the  contingent  fund  will  be  a  part 
of  the  numerical  series  of  vouchers  drawn  against  "Field  Office 
Funds."  In  addition  to  the  budget  item  number,  they  will 
bear  the  designation  "Contingent  Fund"  written  or  stamped 
across  their  face  as  a  double  check  to  avoid  error  where  the 
object  of  expenditure  resembles  objects  ordinarily  reported 
under  other  budget  items. 

8.  Quarterly  report. — On  the  first  day  of  each  quarter,  or  as 
soon  thereafter  as  possible,  every  field  office  will  report  to 
the  Commission  the  total  of  its  receipts  and  expenditures  for  the 
quarter.     A  form  for  this  report  has  been  provided. 

9.  Transmission  of  vouchers. — Vouchers  covering  payments 
from  field  office  funds  will  be  transmitted  to  the  Commission 
at  the  close  of  each  quarter.  The  vouchers  will  be  mailed  under 
separate  cover  from  a  letter  of  transmittal,  a  form  for  which  has 
been  provided.  This  letter  will  show  the  total  number  of 
vouchers  transmitted,  together  with  their  serial  numbers.  At 
the  close  of  a  quarter  vouchers  will  at  times  not  have  been  re- 
turned to  the  field  office  by  parties  to  whom  sent  for  receipt. 
In  such  case  no  vouchers  will  be  transmitted  until  all  vouchers 
issued  during  the  quarter  have  been  returned  to  the  field  office 
properly  receipted.     An  exception  will  be  made  only  where  an 

*  unusual  delay  of  more  than  two  weeks  is  likely  to  occur. 


SAMPLE    FORM    OF   QUARTERLY    FINANCIAL    REPORT. 

191 •• 

Internationai.  Hkai^th  Commission, 

725  Southern  Building,  Washington,  D.  C. 
Dhar  Sirs:  Herewith  please  find  quarterly  financial  report 
for  the  quarter  ending. 191 .  . 


RECEIPTS. 

Foreign  currency. 

Receipts. 

Expenditures. 

Balance  from  preceding  quarter 

*  *  * 

Receipts  during  quarter 

*  *  * 

EXPENDITURES. 

Deficit  from  preceding  quarter 

*  *  * 

Charged  against  field  office  funds,  voucher 
Nos. to 

*  *  * 

Charged  against  home  office  funds,  voucher 
Nos. to 

*  *  * 

Totals 

Balance  to  next  quarter . 

Summary  in  U.  S.  Currency. 

Total  receipts 

*  *  * 

Total  expenditures 

*  *  * 

Balance  to  next  quarter 

Very  truly  yours, 


Director  for , 


SAMPLE  FORM  OF  LETTER  OF  TRANSMITTAL 
OF  VOUCHERS. 


191 


IntiSrnationaIv  HeaIvTh  Commission, 

725  Southern  Building,  Washington,  D.  C. 

Dkar  Sirs:  Under  separate  cover  I  am  forwarding  to  you 

original  vouchers,   together  with   supporting   bills, 

both  receipted,  covering  expenditures  made  during  the  quarter, 
ending 191..  out  of  Field  Office  Funds  and  num- 
bered serially  from  to  

original  vouchers  drawn  against  Home  Office  Funds 

and  numbered  serially  from to 

were  forwarded  to  the  Commission  during  the  quarter. 


Very  truly  yours. 


Director  for 
43 


SAMPLE  FORM  OF  VOUCHER. 


CHARGED  TO  BUDGET 

Int 

NO. 

0-^  PANAMA 

AND  PAID  FROM 

HOME 

OFFICE  FUNDS 

THE  ROCKEFELLER  FOUNDATION 

ernational  Wealth  (Eomnit00lon 

'24  SOUTmSRN  building.  WAHINGTON.  D  C 

To 

VOUCHER  No.' 

J 

i 

Oripimal 

Approved  for  Payment 

ucceivce  ttom  tbc  International  Wcaltb  Commission 

IN  FULL  ACCOUNT  AS  PER  STATEMENT  ABOVE. 

DinccTon  roo  PiaiM 

(wii  M£«e). 

please  insert  date,  sign,  and  return  all  copies  of  this  voucher  (with  ahacmeo  papers)  to 
72s  southern  builoihc.  washington.  0.  c. 

<-i-  f*  ^.r  ^ti*  £'^i '  I  i'^v'-^i ! '  r-  • 


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